You are assigned as the primary nurse

You are assigned as the primary nurse for a 89 yr old female with severe dementia who has been bedridden due to a severe pressure ulcer on her coccyx. She is completely dependent for all ADLs, incontinent of both urine and bowel and eats and drinks poorly. The pressure ulcer started several months ago and the staff in the LTC were unable to contain it despite various nursing interventions. She has beed admitted for IV hydration, wound assessment and care planning. 1- ASSESSMENT- Identified actual or potential assessment criteria in the scenario. Indicated what would be important to assess when preparing to identify the nursing diagnoses. 2. NURSING DIAGNOSIS- A). Wrote a diagnostic label that relates to an Actual problem-focused diagnosis that the client is experiencing including the “related to” factors and the evidence to support the diagnosis (3-part diagnosis). B.) Wrote a diagnostic label that relates to potential/risk problem or risk that the client is experiencing, including the “related to” factors. ( 2-part diagnosis). C.) Wrote a diagnostic label that focused on wellness/health promotion/teaching for the client, including the evidence to support diagnosis. (2-part diagnosis). 3. GOALS/EXPECTED OUTCOMES: Wrote one goal for each diagnosis that included measurable criteria using the SMART method. 4. INTERVENTIONS: Included 2 nursing interventions per goal: – 2 for the actual – 2 for the potential/risk – 2 for health and wellness Provided rationale for interventions with evidence from literature.

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