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NURSING PROCESS PROJECT

Nursing Process Project

By: Alysia Brillhart

NRS 105

Instructor: Charity Furcsik

Due Date: 11/24/2020

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NURSING PROCESS PROJECT
What is the nursing process? The nursing process can be easily explained by using the

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

demographic data, do a head-to-toe assessment, gather information on labs/diagnostic tests that

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

cancer, hypercholesteremia, hypothyroidism, mass on ovary, enlarged pituitary gland,

sarcoidosis, venous thrombosis and sleep apnea. Past surgical history included a cesarean section
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NURSING PROCESS PROJECT
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

ranged from 3 to 8 on a pain rating scale of 0-10.

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

numbness and tingling in the upper and lower extremities.

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

patient was taking.

 Labs/Diagnostics:

Lab/diagnostics conclusion Nursing intervention

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.

b. Chloride: 111 b. The patient’s high b. Upon the patient’s return

(high) chloride level may
indicate that the patient
may have been slightly
dehydrated when this lab
was drawn. The patient
was NPO when the
morning labs were drawn.
from surgery, she was
allowed to sip on ice
water, so I provided her
some ice water. Then,
once she tolerated sipping
the ice water following
surgery, I provided other
liquids.

c. Glucose: 137 and c. Continue to check blood

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141 c. The patient is a diabetic,
so their levels tend to
fluctuate based on what
they eat and drink.
d. MRI without
contrast of the d. The MRI without contrast
right ankle of the right ankle showed
that the patient had an
infection and partial
tearing of the Achilles
tendon. In addition, it
showed edema and
tenosynovitis.
glucose AC/HS as ordered.
Give antidiabetics as
prescribed.
d. The patient had wound
debridement surgery done
to the right ankle to clean
the wound out. Additional
interventions may include
cleansing the wound with
antibacterial solution and
dressing the wound as
prescribed.

 List of medications:

Medication and dose Why is the Nursing Major side effects

patient on this interventions
med?

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.

Nateglinide 120mg/1 tab PO

BIDAC Used to treat Obtain blood sugar Hypoglycemia
Type 2 Diabetes. AC/HS.

Lispro/Humalog SQ TIDAC Type 2 Diabetes Obtain blood sugar Hypoglycemia

AC/HS.

Atorvastatin 10 mg PO QHS High cholesterol Monitor cholesterol Diarrhea, loss of

levels. appetite, nausea,
muscle pain
Levothyroxine 200 mcg/1 tab
AM 30 minutes before Hypothyroidism Monitor thyroid Muscle weakness,
breakfast levels. headache, nervousness.
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 List of medications:

Medication and dose Why is the Nursing Major side

patient on this interventions effects
med?

Bupropion 300mg QAM Depression Monitor for Headache, dry

depression. mouth, trouble
sleeping

Ertugliflozin 5mg PO Type 2 Diabetes Obtain blood sugar Hypoglycemia

AC/HS

Lisinopril 10mg PO Hypertension Assess BP before Hypotension

giving.

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

Actual and potential health problems:

Abnormal Data: Analysis of Data: (what does
it mean?)
Right foot pain with The patient had her right
pain rating of 3-8 Achilles tendon debrided and
is experiencing a lot of pain
following the procedure.
Potential Health Problems:
(Can this data lead to any other
issues?)
This data could lead the patient to
experience additional pain if it is not
treated accordingly.

Non weight-bearing The patient is non weight
on the right foot bearing on her right foot and
requires assistance to get out
of bed. The patient wanted to
get out of bed without help.
This could potentially lead to a safety
risk if the patient would have tried to
get out of bed without assistance,
which may lead to the patient falling.

Wound debridement This could potentially mean that the

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NURSING PROCESS PROJECT
and cellulitis on right Since the patient has a wound, infection could become worse if the
Achilles tendon this may increase the risk of patient does not receive the
the current infection from prescribed antibiotics and if the
becoming worse. wound is not cared for using aseptic
technique.

BMI 38.91kg/m2, This could potentially lead to the

Weight 237.6 pounds Due to comorbidities and patient’s condition to worsen, cause
increased weight, this patient additional comorbidities, and could
may benefit from a healthier put the patient’s health at risk.
diet and weight reduction.

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

Outcome/Goal (short and long term):

STG: The patient will verbally report if experiencing pain on scale of 0-10 in the right foot during my
shift.
LTG: The patient’s right foot will return back to normal structure and function as evidenced by intact
skin, no swelling and no pain in right foot by follow up appointment in one month.

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
ADL’s PRN.
4. The nurse will teach the patient
nonpharmacological ways to relieve pain,
such as relaxation techniques and/or
meditation once a shift.
Assisting the patient with ADL’s will help the patient
conserve energy.
Teaching the patient nonpharmacological ways to relieve
pain may help promote comfort to the patient.

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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NURSING PROCESS PROJECT

Care Plans:
Patient Problem: Imbalanced Nutrition: More Than Body Requirements related to poor dietary
habits

Evidence: BMI of 38.91kg/m2, weight of 237.6 pounds

Outcome/Goal (short and long term):

STG: The patient will verbalize ways to decrease weight within 24 hours.
LTG: The patient will display weight loss of 2-5 pounds by follow up visit in one month.

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
choices to the patient prior to discharge.
4. Educate the patient on the benefits of
weight reduction PRN.
Evaluation
Patient expressed a willingness to reduce weight and stated that she wants to try to eat
healthier and start exercising daily.
This will help promote a healthy lifestyle prior to
going home and hopefully increase the likelihood
of the patient following a healthier diet.
Educating the patient on the benefits may help
encourage them to want to strive for a healthier
lifestyle in order to reduce the likelihood of
worsening health conditions.

Care Plans:
Patient Problem: Impaired Tissue Integrity related to infection of the right foot
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Evidence: localized pain in right foot (pain rating 3-8)

Outcome/Goal (short and long term):

STG: The patient will report any altered sensation or pain in right foot during first 24 hours of
care.
LTG: The patient’s right foot will return back to normal structure and function as evidenced
by no pain and intact skin within 2 months following surgery.

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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NURSING PROCESS PROJECT
foot

Outcome/Goal (short and long term):

STG: The patient will demonstrate the use of the call light to minimize risk for falls when
having the urge to go to the bathroom every 2-4 hours.
LTG: The patient will walk with her walker without the need for additional assistance by
follow up visit in one month.

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.
4. Teach the patient how to do active
and passive ROM exercises every 2-
4 hours.
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.
ROM exercises will help promote blood flow,
prevent stiffness of the joints and help maintain
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

an appropriate plan of care based on their needs.

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

distribute a medication that may cause health risks.

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

the spread of COVID-19.

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References

Deitrick, K., Adams, J., & Davis, J. (2020, November). Emergency Nursing Care of Patients

With Novel Coronavirus Disease 2019. Retrieved from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7368907/

QSEN (n.d.). from https://qsen.org/competencies/graduate-ksas/