Objective data are observable and measurable. This information is usually obtained through the senses as sight, smell, hearing and touch, during the physical examination of the patient. During Mary was assessed, this is the objective data: symmetrical abdomen, bowel sounds in all quadrants, tender to palpation in the lower quadrants, guarding, skin is warm and moist and her lips and mucous membranes are dry.
Subjective data could be described as the vision that the individual has of a situation or series of events. This information cannot be determined by the nurse regardless of relationship or communication with the individual. Subjective data are often obtained during nursing anamnesis and include perceptions, feelings and ideas about the patient himself and on personal health status. Examples include descriptions of pain the patient does, weakness, frustration, nausea or confusion. Mary this information provided to the nurse that she was experienced nausea, vomiting, abdominal pain increasing in severity, diarrhea, and fever, and dry mouth. She tells, the nurse that she have had about abdominal pain for 12 hours with nausea, vomiting, and diarrhea.
Nursing note:
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Patient female is a 19-year-old college freshman. With complaints to be having nausea, vomiting, abdominal pain increasing in severity for about 12 hours, diarrhea, a fever, and dry mouth. Patient states “these symptoms, all started after supper in the student cafeteria on campus. During physical assessment, which reveals the following: symmetric abdomen, bowel sounds in all quadrants, tender to palpation in the lower quadrants, guarding, skin is warm and moist, lips and mucous membranes are dry. Factors that should be taken into account is hers ethnic, religion, culture, family history and medical history. After the emergency services have responsibility to make the initial assessment of all patients seeking health care and prioritize according to severity. Triage is defined as clinical and systematic review of all patients coming to the emergency, in order to assign priorities for assessments and treatment through a series of predetermined criteria and classification method for determining the level of urgency. Its implementation requires a proper structure, both physical and personal and a rating scale to be valid, useful and reproducible. The nursing diagnosis in the context of nursing, is a synthetic view of human responses of the individual, family or community, that require health care in preventing disease, maintaining and improving health, or to life. Its objective is to identify the health status of a patient or client, and issues relating to health care. In this case it would be needed, data collection, collection of relevant statistical data to develop a diagnosis. Signal detection patterns and changes in the physical state. Establishment of hypotheses, possible alternatives that could have caused signs or previous patterns. Validation steps to dismiss other hypotheses, and to simplify a single problem. Diagnosis based decision on the validation problem. In this case the patient could say that the diagnosis is compatible with botulinum food poisoning.
Botulism is a neuroparalytic disorder characterized by the appearance of a descending flaccid paralysis produced by Clostridium botulinum toxin. The causal agent of this disease is a gram-positive anaerobic bacillus survives in soil and marine sediments through the formation of vegetative spores. Clostridium botulinum spores germinate favored by certain environmental conditions. The bacillus, during growth and autolysis releases a potent neurotoxin responsible for the symptoms of the disease. There are 7 types of toxin designated A through G. The toxin is absorbed from the intestinal tract and into systemic circulation to reach neuromuscular endings. At this level it binds to receptors on nerve endings
cells Cholinergic blocking the release of acetylcholine in the parasympathetic synapses and neuromuscular junctions. Following nerve transmission is blocked, resulting in both a dysfunction of the autonomic nervous system level and at muscular level. Caused by ingestion of botulinum toxin preformed. This situation occurs when food contaminated with spores of Clostridium botulinum is stored under anaerobic conditions that permit germination, multiplication and toxin production. This toxin is odorless and tasteless and denatures at temperatures above 80 °.
The SMART goal for the patient’s diagnosis of diarrhea is that the patient will defecate formed, soft stool every 1 to 3 days and will express relief of cramping with little or no diarrhea. The intervention to meet this smart goal is the administration of fidaxomicin, a narrow spectrum antibiotic, to treat the infection of Clostridium difficile (Sears, 2013). Another nursing intervention for the treatment of diarrhea is assessing the patient for sodium and potassium loss, as well as explaining the prevention methods to avoid the spread of excessive diarrhea (Mitchell, 2014). The nurse must also provide proper skin integrity care to the peritoneal are and make the environment safe and easy for access to the bathroom. The SMART goal for the patient’s diagnosis of acute pain is that the patient will state relief of pain in abdominal area after treatment with opioids in a 24hr period. The nursing intervention for acute pain is the administration of opioids as well as positioning to keep patient in as much comfort as possible and take pressure off of the abdominal area. The nurse must also assess the patient’s vital signs and pain level
JIU-CONG, Z., LI, S.,& QING-HE, N. (2010). Botulism, where are we now?. Clinical Toxicology (15563650), 48(9), 867-879. doi: 103109/15563650.2010.535003
Among hospitalized patients around the world, Clostridium difficile is the primary source of infectious diarrhea. Previously, continuously unbalanced intestinal microbiota, usually due to antimicrobials, was deemed a precondition of developing the infection. However, recently, there have been alterations in the biology from virtually infecting the elderly population exclusively, wherein the microbiota in their guts have been interrupted by antimicrobials, to currently infecting individuals within of all age groups displaying no recent antimicrobial use. Furthermore, recent reports have confirmed critical occurrences among groups previously assumed to be of minimal risk—pregnant women, children, and individuals with no previous exposure to antimicrobials, for instance. Unfortunately, this Gram-positive, toxin-producing anaerobic bacterium is estimated to cost US critical care facilities $800 million per year at present, suggesting the need for effective measures to eliminate this nosocomial infection (Yakob, Riley, Paterson, & Clements, 2013).
The framework of this model is utilized throughout hospital settings to form a basis for all nursing decisions in respect to nursing diagnosis, care plans, discharge planning, and quality assurance (Reynolds & Cormack, 1991). This conceptual model focuses on the effects of internal and external environments that contribute to someone’s behavior. Pain (being the internal force) in patients with altered mental status usually manifests externally in non-verbal cues. Nursing as the external force can use tools that focus on the non-verbal cues given by the patients to accurately assess the pain and properly treat it.
Some strains of this microorganism produce C. perfringens enterotoxin (CPE), a group of toxins that cause a variety of adverse effects in the host. Strains of C. perfringens are classified as 5 biotypes, A – E, depending on the production of four major enterotoxins (α, β, ε and ι). In addition, strains of C. perfringens may also produce a number of other toxins including neuraminidase, hyaluronidase, and collagenase. For example, α-toxin, produced by C. perfringens type A, is primarily responsible for the production of gas gangrene. However, only roughly 5% of C. perfringens carry the CPE gene that codes for the production of these toxins. CPE is inactivated at 74oC.
... joy Mrs. L got from seeing her cat. Health in this scenario is shown mostly notably when Mrs. L got relief from Morphine and stated she knew she was going to die but felt “ok for now”. Health in this case was measured by an improvement in pain and not an absence of illness. Finally, nursing in this scenario is exemplified in many ways. In the paragraph above I begin by ensuring the patient’s confidentiality. Mrs. L was placed at the center of care. I collaborated with other nurses and all those in the environment to assure the best care possible. Through direct care, teaching and advocacy I delivered the exact type of care I would wish for myself, or someone I loved, if I were in Mrs. L’s place.
This piece of work will be based on the pre-assessment process that patients go through on arrival to an endoscopy unit in which I was placed in during my second year studying Adult diploma Nursing. I will explore one patient’s holistic needs, identifying the priorities of care that the patient requires; I will then highlight a particular priority and give a rational behind this. During an admission I completed under the supervision of my mentor I was pre-assessing a 37 year old lady who had arrived to the unit for an upper gastrointestinal endoscopy. During the pre-assessment it was important that a holistic assessment is performed as every patient is an individual with unique care needs as the patient outline in this piece of work has learning disabilities it was imperative to identify any barriers with communication (Nursing standards 2006).
the patient's life and feelings to get an understanding of what the patient goes through on
Assessment of a patient’s health status is the collection of data through nursing assessment techniques,
For example, when implementing a teaching and learning tool for a patient, the nurse must first assess the patient in order to identify the areas of teaching needed. In this example we’ll look at J.L. who is a seventy two year old male with a history including the following: hypertension, heart murmur, pacemaker, CAD, cardiomyopathy, hyperpotassemia, hypercholesterolemia, cigarette smoking and diabetes. In addition to the patient’s past medical history, assessment data is needed to help identify teaching needs. In this example, J.L. was found walking in his apartment without any shoes or socks on and was seen exiting the apartment complex with his shoes and no socks. Upon examination of both his left and right feet, the top and bottom of hi...
D. standing near her room, breathing sharply. While asked what has just happened, she answered, ‘I feel dizzy and can faint!’ Mrs. D. then explained that she rose up from her chair in the television room and felt lightheaded. I decided to bring her to the room hoping she would feel less dizziness if she could sit. After consultation with my mentor and third year unit nursing student, I decided to perform measurement of her vital signs. Since only electronic sphygmomanometer was available for me that time, I had to use it for my procedure. Gladly, I discovered that I have already used such equipment in my previous nursing practice. Using the standard sized calf, I found that her blood pressure was 135/85, respirations were 16, and her pulse was 96 beats per minute (bpm). However, I decided to recheck the pulse manually, founding that it was irregular (78 bpm). The patient stated that she felt better after rest. Immediately after the incident I made a decision to explore carefully the medical chart of Mrs. D., along with her nursing care plan. That helped me to discover multiple medical diagnoses influencing her
In theory and practice, the focus of nurses is on the response of the individual and the family to actual or potential health problems. To evaluate patient care steps has to be taking that incorporates the collection of data and processing that data through critical thinking. The nursing process is essential because it incorporates this concept into a well throughout steps ...
Assessment is the accurate collection of comprehensive data pertinent to the patient’s health or the situation (“American Nurses Association,” 2010). Assessment is the first step in the nursing process and the most important. Assessment is the accurate collection of the patient’s health date including both subjective and objective information. Subjective data includes information that can only be described or verified by the patient. This may include chest pain, headache, or body aches. Objective date is data that can be observed and measured. This type of data is obtained using inspection, palpation, percussion, and auscultation during the physical exam. Objective data can also be provided through diagnostic testing. This is important for proper diagnosis, planning, and intervention. Examples of this may include vital signs, warm and moist skin, and coughing up yellow colored sputum.
A diagnosis is the expert and clinical judgment of the patient 's present or potential medical issue. During the 1970s and 1980s, a controversy about nurses using the term “diagnosis” began. Up until then, only physicians held the ability to diagnose a patient. But the nursing diagnosis is completely different than a medical diagnosis. In other words, a nursing diagnosis is a judgment based on a comprehensive nursing assessment (NANDA, 2013). Nursing diagnoses must be promoted by data or signs and symptoms.
The art of nursing is defined as being mindful of what the patient needs emotionally and physically. In order to fully practice the true art of nursing, one must have compassion, a caring attitude, and good communication skills (Palos, 2014). Another definition of the art of nursing is having a personal connection between the nurse and the patient (Kostovich & Clementi, 2014). My personal interpretation of the art of nursing is to be aware of the patient’s specific needs; being physically present when they need you; respecting the patient and the family; and being gentle when delivering nursing care. The science of nursing on the other hand is having the knowledge, skill, critical thinking and evidence-based practice integrated with nursing practice (Palos, 2014). With this concept, a nurse must have a good understanding of various types of diseases and be able to identify the symptoms associated with it. Medicine is an important part of science. Knowledge about the different drugs and knowing how to safely administer them are crucial in nursing care. Performing medical procedures and updating current nursing skills according to new evidence-based research is critical to achieve best patient outcome. A nurse should employ critical thinking skills and good decision making as well. My own definition of science of nursing is providing safe