Nanda nursing diagnosis for endometrial cancer

PATIENT/CLIENT DATA - CLINICAL DECISION-MAKING WORKSHEET

Student Name: Q. A

Week: 2

Dates of Care: 09/01/2020

Patient Initials

M.C

Sex

F

Age

73

Room

5026

Admitting Date

9/19/2020

Admitting Chief Complaint: What symptoms cause the patient to come to the hospital?

Pelvic Pain. Patient had increasing pelvic pain, UTI, Dysuria.

Attending physician/Treatment team:

M.D

Consults:

Oncology

Present Diagnosis: (Why patient is currently in the hospital)

Increased Pelvic Pain

Hyponatremia

Intractable abdominal pain

ER Management: (if applicable)

N.A

Allergies:

Bisphosphonates

Tomatoes

Code Status:

Full Code

Isolation: (type and reason)

N.A

Admission Height:

165.1cm ( 5’r’’

Admission Weight:

62.5kg (137lb 11oz)

Arm Band Location (colors & reasons)

N.A

Communication needs: (verbal, nonverbal, barriers, languages) (Osborn pages 258 - 262)

Past Medical History: (pertinent & how managed)(Osborn Chapter 9)

Dental Crowns Present

Diabetes Mellitus (HCC)

Hx of presenting hazard to health

Hyperlipidemia

Hypertension

Uterine cancer (HCC)

Pathophysiological Discussion ( Pelvic Pain)- Discuss the current disease process at the cellular level (in your own words). Explain why this patient is encountering this particular health deficit. What is the relationship of this current health alteration to the patients other medical conditions? Describe the current disease process the patient is encountering: etiology, epidemiology, pathophysical mechanism, manifestations and treatment (medical and surgical). Also note the complications that may occur with these treatments and the patient’s overall prognosis. Include appropriate references and use APA format.

CDH II: attach a research article pertaining to diagnosis of patient. Write a summary about the article.

List of nursing diagnoses (NANDA format). Place diagnoses in priority order and provide rationale for priority setting.

Priority

Nursing Diagnosis

Related to

As Evidence By

Rationale (reason for priority)

1

2

3

4

5

6

7

8

9

10

Assessment as evident by (AEB) or data collection relative to the nursing diagnosis
Patient Goal(s)
Patient Outcome (objective, expected or desired outcomes or evaluation parameters)
Interventions/
Implementations
Evaluation
Guidelines for Nursing Process

Nursing diagnosis consists of the diagnostic label, “related to” and the “as evidence by” components (see below).

Diagnostic label: Is selected from the NANDA International Diagnosis.

Related to: the condition or etiology of the problem the patient is experiencing. Should be in domain of nursing practice that nursing interventions can aggect. Should be the medical diagnosis.

Assessment as evident by (AEB), or data collection relative to the nursing diagnosis

Patient Goal(s)

Outcome (objective, expected or desired outcomes or evaluation parameters

Interventions/

Implementations

Evaluation

Assessment supports the nursing diagnosis above. The assessment should reflect the “defining characteristics” that are expected to be present for that diagnosis to be appropriately utilized.

Review Chapter 7 in Osborn for the elements of assessment that should be contemplated.

Types of data: subjective & objective

Sources of data

Nursing health history

Physical examination

Diagnostic data

“A statement of purpose describes the aim of nursing care” (Osborn et. al., p. 113)

Refer to Chapter 7 in Osborn for review of nursing diagnosis (may have more than one outcome for each nursing diagnosis)

May be short or long term assists in the ongoing evaluation of the patient’s progress to achieving the goal.

Should be acceptable by the patient and the nurse, realistic, specific and measurable (Osborn, et al., 2010)

Stated realistic behavioral terms that can be observed, measured and relevant to the identified nursing diagnosis.

Intervention – the planned nursing actions that are likely to achieve the desired outcomes (Osborn, et al., 2010).

Implementation – the carrying out of the planned nursing interventions (Osborn, et al., 2010)

Interventions should reflect on going assessment and activities that will assist in achieving the goal/outcomes.

Interventions should reflect indendent nursing practice as well as collaborative practice.

Interventions should reflect the needs of this specific patient not a generic listing of possible interventions.

Interventions should include specific like schedules, food choices, frequency, etc….

Focuses on change and compares the changes with the outcomes (Osborn et al., 2010).

Essentially this is a reassessment of the patient and the responses as to the interventions implemented.

Compare actual patient behaviors with expected behaviors.

Give reasons why or why not each outcome has been met.

Consider the effectiveness of the nursing intervention, time elements.