Nursing Observation

Overall I think that I had a decent day. There were definitely things that I felt I did not spend enough time on and other things that I didn’t get to due to other activities, but also things that I didn’t think of until after I left. Overall one of my main focus points of the day with P.L. was to improve his overall mood. From the moment I met him I got the sense that he was in a depressed and solemn mood. As I talked to him I found out that for the past three months he has been in and out of the hospital and that seems to be talking a toll on his mood. When I can into his room to do certain assessment and asked his permission, most of the time his response was disengage. I did end up engaging him in conversation before each of my assessments, usually about his past. He talked a lot about his time in the military and seemed to be a positive subject for him, especially when I ask about all the places he’s been and his favorite place he’s been. I noticed that when we were conversing about this subject he was more
I felt that impaired tissue perfusion had the highest risk for patient injury, which is why I placed that as my top priority. I placed imbalanced nutrition: less than body requirements because the P.L. has consumed so little nutritional calories that day, 0% at breakfast and minimal at lunch which was unrecorded as he was still working on it when I left. This in concerning because inadequate nutrition slows the healing process and can cause skin integrity impairment. Also, because of the lack of nutrition and medication side effect P.L. was constipated and hadn’t had a BM since 1/18 and is nauseated. Lastly, I placed impaired physical mobility last because with the spinal injury and immobilization of the neck along with the medications side effects and impaired nutrition, this patient has a higher risk of