Okay, so here I am again. I think this time I have collected more data, but not as much as I would have liked bc I ran out of time. I have an 82 yr old female who had a syncopial episode and fainted. She fell and had a fracture to her left femoral neck. She has had hip surgery in the past, so this was nothing new for her. She has a history of chronic kidney disease stage II, HTN, hypothyroidism, anemia, osteoarthritis, and syncope/dizziness. Her lab values for HGB: 10.5(they are low), HCT: 30.6(low also), RBC: 3.9(Low as well). Okay, so for a nursing diagnosis I have....Ineffective tissue perfusion r/t decreased hemoglobin concentration in the blood aeb weak peripheral pulses. Is this good? Am I on the right track this time? And how in a 4 hour shift am I supposed to have 10 interventions? Is that possible? Here is what I have so far and I just do not feel like it is good enough. Any feed back is appreciated. I also have to come up with 5 goals, I'm working on it, but only have one.
Goals:When shift is over the patient will be able to verbalize understanding of condition and therapy regimen.
1-Establish rapport with patient. Trust will help the patient open up and tell me more about whatis going on and what happened when she had her accident.
2-Perform handhygiene to prevent the spread of bacteria to patients wounds.(My instructor suggests we must always have this on as an intervention and that the first intervention should be some type of assessment)
3-Monitor vital signsto have baseline data. Report any abnormalities.
4-Perform full body assessment on patient and not any abnormalities.
5-Encourage quiet and restful atmosphere.
6-Encourageambulation to promote venous return.
7-Discourage sittingwith legs crossed or standing for long periods of time and wearing constrictiveclothing.
8-Encourage patientto each foods rich in iron to help with anemia.
9-Administermedications as ordered.
10-Scheduleactivities for periods when patient has the most energy.
Being sleep deprived is really not helping me, but am I on the right track? Is this good enough?