Finalnursing Process Project
Finalnursing Process Project
Finalnursing Process Project
NRS 105
acronym ADPIE. The A in ADPIE stands for assessment, which involves gathering data on a
patient. The D in ADPIE stands for diagnose, which involves analyzing data that you obtain and
determine what the patient problems are. The P in ADPIE stands for plan, which is when the
nurse sets obtainable goals and comes up with intervention to help promote the patient’s health.
The I in ADPIE stands for implementation, which is when the interventions are put into action.
The E in ADPIE stands for evaluation, which is when the nurse evaluates the care plan for the
patient to determine whether the interventions and goals were effective or not.
For the purpose of this nursing process project, we were asked to choose a patient who
we had in clinical to do this project on. We were asked to gather pertinent information such as
were performed and medications that the patient was on. In addition, we were asked to use our
critical thinking skills to identify any actual or potential problems that our patient may be at risk
for related to abnormal data that we obtained. Then, we were asked to produce four care
plans for the patient that included a priority nursing problem, proper nutrition related to an actual
or potential health problem, need for safety and a risk for diagnosis.
The patient that I chose to do this project on was J.N. The patient was a 64-year-old white
female. She was religiously affiliated as a Christian, a high school level of education and a
retired factory worker. The reasoning for her most current hospitalization was due to a right
Achilles tendon infection and cellulitis. Her social history included being married and having one
child. Past medical history included type 2 diabetes, hypertension, depression, arthritis, skin
sarcoidosis, venous thrombosis and sleep apnea. Past surgical history included a cesarean section
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in 1997, cholecystectomy in 2000, carpal tunnel surgery in 2010 and ACL surgery in 2012.
Family history included her father having type 2 diabetes and both parents having hypertension.
When I did a head-to-toe assessment on the patient, I was able to gather quite a bit of
subjective and objective data. During my general survey of the patient, I found that the patient
was cooperative, calm, and talked in clear, complete sentences. The patient was well groomed
and well nourished. The patient’s weight was 108kg/237.6lb, height was 167.6cm and BMI was
38.9kg/m2. In addition, her gait appeared to be fairly steady with the help of a walker and
standby assistance.
The patient’s vital signs were in stable condition during my care. I obtained the first set
of vitals following her return from surgery and four hours after that. The first set of vitals that I
obtained was a blood pressure of 130/70, pulse of 85, oxygen saturation of 95% on room air,
respirations of 17 and temperature of 97.8 degrees Fahrenheit. The final set of vitals that I
obtained was a blood pressure of 121/69, pulse of 88, oxygen saturation of 93% on room air,
respirations of 17 and temperature of 97.9 degrees Fahrenheit. During my care, J.N.’s pain level
During my assessment, I found that the patient was alert and oriented times four. When
assessing the patient’s skin, the skin that I could visualize was warm and the color was normal
for her ethnicity. However, her right leg had a dressing and ace wrap covering it so I was unable
to assess her right leg. The patient’s head/face was normocephalic. J.N.’s eyes showed PERRLA
and she wore glasses for farsightedness. The assessment of her ears/nose/throat showed that
gross and fine hearing were intact, along with moist mucous membranes. The assessment of her
lungs/chest indicated that her lungs were clear upon auscultation of both anterior and posterior
lung sounds with unlabored breathing pattern on room air. The patient’s heart was a regular
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rate and rhythm with auscultation. J.N.’s abdomen was soft, nontender and nondistended with
bowel sounds hypoactive and present in all four quadrants. The assessment of the patient’s
musculoskeletal system revealed that hand grasps were equal and strong bilaterally. However,
the pedal pushes on the right showed to be weaker than the left side. The patient denied
Once my assessment was completed, then I was able to look over the patient’s chart for
the labs and diagnostic testing that was done, along with medications that were being prescribed.
There were only three sets of labs that were abnormal and there was an MRI that was done on
my patient. In addition, my patient was on a lot of medications. Below, you will find a chart
with the abnormal labs, diagnostic tests that were obtained, along with the medications that my
Labs/Diagnostics:
a. WBC: 4.10 (low) a. The patient’s low white a. Report abnormal labs to
blood cell count might be doctor. Continue to
due to past history of monitor WBC count.
sarcoidosis and cancer.
List of medications:
Cefazolin 2g IVP Q8hr The patient has Monitor labs and IV Swelling, redness,
an infection, so site. pain, soreness at IV
this is being used site.
to treat the
infection.
PRN:
Tylenol 650mg PO Q4hr for Pain Assess pain level Nausea,
pain 1-3 before giving. headache,
stomach pain
Oxycodone 1 tab Q6hr for pain Pain Assess pain level Nausea,
4-6 before giving. vomiting, dry
mouth, weakness,
drowsiness
Non weight-bearing The patient is non weight This could potentially lead to a safety
on the right foot bearing on her right foot and risk if the patient would have tried to
requires assistance to get out get out of bed without assistance,
of bed. The patient wanted to which may lead to the patient falling.
get out of bed without help.
Care Plans:
Patient Problem: Acute Pain related to Achilles infection
Evidence: Patient reports pain levels of 3-8 on a 0-10 pain rating scale
Interventions: Rationale:
1. Assess patient’s right foot for redness, Assessing the patient’s pain level will allow the nurse to
swelling, pain and heat every 2-4 hours. know if pain medication is effective or not.
2. The nurse will administer prescribed pain Administering pain medication will help relieve patient’s
medication as ordered. pain and provide comfort.
3. The nurse will provide assistance with Assisting the patient with ADL’s will help the patient
ADL’s PRN. conserve energy.
4. The nurse will teach the patient Teaching the patient nonpharmacological ways to relieve
nonpharmacological ways to relieve pain, pain may help promote comfort to the patient.
such as relaxation techniques and/or
meditation once a shift.
Evaluation
The patient verbalized her pain level during my shift as a 3 during my last safety check of the shift. I was
able to report this pain rating to her nurse so that she was able to receive pain medication to help promote
comfort. In addition, I promoted comfort by positioning the patient’s right foot on a pillow.
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Care Plans:
Patient Problem: Imbalanced Nutrition: More Than Body Requirements related to poor dietary
habits
Interventions: Rationale:
1. At the beginning of the shift, assess This will show whether or not the patient has the
the patient’s readiness to initiate a willingness to want to lose weight and be
weight loss regimen at the beginning healthier.
of the shift by asking questions such
as, “how do you feel about starting a
weight loss program?”
2. During the beginning of the shift, A visual record of what they’re eating may help
encourage the patient to keep a daily them make healthier choices.
log of caloric intake.
3. Provide a pamphlet of healthy food This will help promote a healthy lifestyle prior to
choices to the patient prior to discharge. going home and hopefully increase the likelihood
of the patient following a healthier diet.
4. Educate the patient on the benefits of Educating the patient on the benefits may help
weight reduction PRN. encourage them to want to strive for a healthier
lifestyle in order to reduce the likelihood of
worsening health conditions.
Evaluation
Patient expressed a willingness to reduce weight and stated that she wants to try to eat
healthier and start exercising daily.
Care Plans:
Patient Problem: Impaired Tissue Integrity related to infection of the right foot
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NURSING PROCESS PROJECT
Evidence: localized pain in right foot (pain rating 3-8)
Interventions: Rationale:
1. Assess the characteristics of the These findings will give information on the extent
wound, such as color, size, of impaired tissue integrity.
drainage, odor every 2-4 hours.
2. Provide tissue care as needed. Tissue care will help promote the healing process.
3. Maintain sterile dressing This technique will help reduce risk of exposure
technique during wound care each to further infection within the impaired tissue
shift. integrity.
4. Teach the patient signs and This will help identify infection and allow the
symptoms of infection, such as nurse to treat it accordingly to prevent it from
redness, swelling, pain, drainage worsening.
at the site PRN.
Evaluation
Patient was able to report pain level to the nurse and verbalize the signs of infection.
Care Plans:
Patient Problem: Risk For Falls
Evidence: The patient just had surgery on her right foot and is non weight bearing on affected
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foot
Interventions: Rationale:
1. Assess the patient’s ability to This will give the nurse an idea of how well the
perform ADL’s with walker and patient is able to ambulate following surgery.
staff assistance within 1-4 hours
following surgery.
2. Promote a safe environment by Promote a safe environment will help reduce the
ensuring that the top side rails are likelihood of the patient falling.
up, bed is in lowest position and bed
alarm is in use during Q2hr safety
checks and PRN.
3. Assist the patient with ADL’s PRN. Assisting the patient with ADL’s will help prevent
the risk of injury following surgery, especially
since the patient is non weight bearing on the right
foot.
4. Teach the patient how to do active ROM exercises will help promote blood flow,
and passive ROM exercises every 2- prevent stiffness of the joints and help maintain
4 hours. muscle strength.
Evaluation
The patient used their call light each time they needed to get up out of bed. The patient also
performed ROM exercises to promote blood flow every 2-4 hours.
In regards to the QSEN Safety reflection, we were asked to describe the aspects of
QSEN, which include K (knowledge), S (skills) and A (attitude). QSEN encourages the
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prioritization of patient-centered care. As a future nurse, it is my responsibility to live this out by
“providing compassionate and coordinated care based on respect for patient’s preferences,
values, and needs (QSEN, n.d.).” Knowledge includes analyzing the needs of the patients based
on their cultural, spiritual and social preferences. Skills include communicating patient values,
providing patient centered care and building therapeutic relationships with patients. Attitude
includes respecting my patients’ personal values, providing support to them and coming up with
I can improve my safety care plan using these aspects by utilizing proper techniques to
administer medications. In addition, I can also improve safety by communicating effectively with
my coworkers and patients. For example, I can assess patient’s allergies to ensure that I do not
I will utilize the KSA in the future to improve safety of my patient care by
communicating effectively with my patients. It is important to assess their cultural and religious
preferences to ensure that their needs are being met and they are not being harmed in any way.
For example, it would be important to assess the religious preferences of my future patients to
ensure that they willingly will consent to receiving a blood transfusion. If they are of certain
religions, then they may refuse this treatment and I need to respect their wishes to promote
safety.
In addition to our care plan, we were also asked to assess if the patient was at risk for
developing COVID-19. According to the article, Emergency Nursing Care of Patients with
Novel
Coronavirus Disease 2019, they stated that “obesity is a major predictor of poor prognosis, along
with high blood pressure, diabetes, heart disease and lung disease (Deitrick, 2020).” My patient
had a lot of comorbidities, such as diabetes, obesity and hypertension that may increase the risk
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of developing COVID-19. In addition, her age may also increase the risk of developing COVID-
19. As a nurse, I can minimize the risk of this patient developing COVID-19 by making sure to
wash my hands thoroughly and by wearing the proper PPE. It is also important to educate
patients on the importance of wearing a mask, social distancing and washing their hands to slow
Deitrick, K., Adams, J., & Davis, J. (2020, November). Emergency Nursing Care of Patients
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7368907/