NM 222 Clinical Nursing Case Essay
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NM 222 Clinical Nursing Case Essay
NM 222 Clinical Nursing I Name: Bindu Komara
Herzing University BSN Program Care Plan Assignment
Assessment Nursing Diagnoses Outcome / Goals Plan Rationale Implementation Evaluation Subjective Data: Pt. stated that she has pain in her legs 8/10
Pt. stated having stiffness in bilateral legs
Objective Data:
Tenderness and redness to bilateral legs joints.
Joint area is warm to touch
VS:BP-144/70,R-20,P-57, T-97.6,02-96% RA
Acute pain related to inflammation as evidence by pain of 8/10 tenderness, swelling and warmth. Impaired physical mobility related presence of joint pain.
Potential for impaired skin integrity related to inflammation to bilateral legs as evidence by redness, tenderness, and warm.
Reduce inflammation result to reduction in pain to 2/10 or at a tolerable level Pt. will be able to have full ROM to bilateral lower extremities (BLE) without complaint of pain.
Patient will have reduce inflammation to BLE to reduce risk of skin integrity
The nurse will Monitor signs and symptoms inflammation and pain throughout the shift. The nurse will perform Full ROM to BLE to prevent contraction.
The nurse will Monitor signs and symptoms inflammation.
To assess level of inflammation and need for quick intervention. Prevent pain. Prevent immobility and contraction.
Prevent impairment to skin integrity and reduce pain
1. Administer acetaminophen 500mg every 4 to 6 hours for pain control. 2. Apply cool compress as tolerable to reduce inflammation.
3. Elevate BLE to reduce inflammation.
4. ROM (10 to 15 repetition) to BLE every 4 hours to prevent contraction/immobilization.
5. Assess circulation, sensation and motion to BLE to ensure adequate perfusion.
6. Reposition BLE to prevent skin impairment.
Goal Not met: Pt. will have pain level of 8/10 to lower extremities with inflammation; tenderness to (BLLE).Pt. will be unable to do ROM (BLLE) at the end of the shift. Goal met: pt. pain 2/10 and verbalize adequate relieve of Inflammations reduced.
Pt. has full ROM to BLE at the end of the shift.
RUBRIC
Excellent Quality
95-100%
Introduction 45-41 points
The background and significance of the problem and a clear statement of the research purpose is provided. The search history is mentioned.
Literature Support
91-84 points
The background and significance of the problem and a clear statement of the research purpose is provided. The search history is mentioned.
Methodology
58-53 points
Content is well-organized with headings for each slide and bulleted lists to group related material as needed. Use of font, color, graphics, effects, etc. to enhance readability and presentation content is excellent. Length requirements of 10 slides/pages or less is met.
Average Score
50-85%
40-38 points
More depth/detail for the background and significance is needed, or the research detail is not clear. No search history information is provided.
83-76 points
Review of relevant theoretical literature is evident, but there is little integration of studies into concepts related to problem. Review is partially focused and organized. Supporting and opposing research are included. Summary of information presented is included. Conclusion may not contain a biblical integration.
52-49 points
Content is somewhat organized, but no structure is apparent. The use of font, color, graphics, effects, etc. is occasionally detracting to the presentation content. Length requirements may not be met.
Poor Quality
0-45%
37-1 points
The background and/or significance are missing. No search history information is provided.
75-1 points
Review of relevant theoretical literature is evident, but there is no integration of studies into concepts related to problem. Review is partially focused and organized. Supporting and opposing research are not included in the summary of information presented. Conclusion does not contain a biblical integration.
48-1 points
There is no clear or logical organizational structure. No logical sequence is apparent. The use of font, color, graphics, effects etc. is often detracting to the presentation content. Length requirements may not be met
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