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Nursing Process Record

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NURSING PROCESS RECORD - NUR 101/105

REFERENCES: TEXTS: DEMOGRAPHIC DATA: Occupation _____Retired___

Religion ________ Catholic_

Race/National Origin ____Italian_

Marital Status ________ Married ____

Developmental Level __Integrity vs Despair__

STUDENT'S NAME _ DATE _3/7/11-3/8/11PT. INITIALS AD_

PT. CARE DATE ADM. _3/5/11 AGE _78 GENDER _M INSTRUCTOR __

MED. DIAGNOSIS ____Esophagitis__

ASSESSMENT NURSING CARE PLAN ACTUAL INTERVENTIONS EVALUATION

DATA COLLECTION NURSING DIAGNOSIS GOAL RATIONALE FOR PLAN

SCIENTIFIC REASON PLANNED INTERVENTIONS

78 year-old-male

h/o Arthritis, legally blind in the left eye, multiple myeloma, colostomy of the left upper quadrant of the abdomen

Patients wife stated, "he is depressed"

Patient states,

"I feel like I'm going to die"

"I can't take care of myself anymore"

"I can't drive"

"My wife does everything for me, I feel ashamed at times"

"I wish my wife didn't have to take care of me"

Nursing Diagnosis:

Powerlessness related to loss of independence

Scientific Reason:

Losses occur at every stage in life, particularly in the later years. As we age, we must cope with a variety of set back- physical, social or emotional-that may, over time, affect our ability to function independently, jeopardizing our freedom from relying on others for our needs. The extent to which we accept and adapt to these losses directly affects the quality of life we achieve and maintain. Some changes that may occur are less control over emotions, less physical energy, hearing problems, less ability to move easily, and memory loss. Loss of independence can create tremendous frustration, feelings of uselessness, and sadness, due to a sense of loss of control in one's life. (#5) My patient has arthritis, which causes stiffness and pain not allowing him to move freely. He is also blind in his left eye sometimes making it difficult for him to perform his every day tasks. He told me how he can not do the things he was once able do to, like driving or performing some of his normal activities of daily living. He states his wife takes care of him and it upsets him that he cannot do it himself. Therefore my patient feels powerlessness, a state in which an individual perceives a lack of personal control over certain events or situations, which affects outlook, goals, and lifestyle. (#2 pg 335) Goal:

The patient will verbalize his feelings towards his loss of independence while under my care

Interventions:

1: Use therapeutic communication skills

a: Using open ended questions

b: Use Attentive Listening

c: Use Touch

d: Use silence

e: Acknowledging

2: Provide PM care while using therapeutic communication

3: Establish a helping relationship

4: Invite patient to participate in plan of care

5: Asses developmental level According to Erikson

6: Evaluate Support System

7: Consider Psychologist consult

a: Open-ended questions specify only the topic to be discussed and invite answers that are more then one or two words. By asking my patient open-ended questions it will allow her to view her thoughts and feelings. (#1 pg 468)

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