Nursing Process
Mrs. Perez’s nurse receives her from the postanesthesia care recovery unit (PACU) to her surgical unit. She realizes that orders are all discontinued when a patient leaves a floor and goes to the surgical suite for surgery. She is looking to admit her patient to her unit and needs a full order set for Mrs. Perez’s care from her surgeon for her postoperative care on the surgical unit. When the patient arrives, the nurse reviews all the new orders the surgeon has written for Mrs. Perez. The nurse will need to introduce herself and have the patient identify herself with two indicators. Once she has done that, she will then do the following to implement the nursing admission to the surgical unit:
- Interview the patient and/or husband and complete a history.
- Take vital signs and complete a physical examination.
- Create a care plan for the patient having acute pain postoperatively.
- Write an admission note using SOAPIE format (Subjective Data, Objective Data, Assessment, Plan, Implementation, Evaluation).
2.Match the nursing process steps with each of the four activities the nurse completes to admit Mrs. Perez. (They are listed above, 1-4).
- a. Assessment
- b. Diagnosing
- c. Planning
- d. Implementation
- e. Evaluation
3.Identify two types of health care team members with whom the nurse would expect to collaborate while caring for Mrs. Perez.
4.Write four questions that the nurse could ask to obtain primary data on Mrs. Perez. From what sources could the nurse obtain secondary data?
- Write a patient focused, measurable, and realistic short-term goal for Mrs. Perez, whose priority nursing diagnosis is Acute Pain.
6.List three interventions that the nurse would want to implement to help Mrs. Perez achieve the identified short-term goal.
