Task №1
Inpatient treatment. Girl 11 years. Diagnosis: the flu. When nursing examination nurse has received the
following information: the complaint of severe headache, dizziness, repeated vomiting, insomnia,
general weakness. He considers himself a patient for two days, the first time the temperature up to
39,8º C and there were phenomena of weakness, weakness, delirium. Objectively: a passive position in
bed. In the mind, but lethargy, pale skin, dry, respiratory rate 30 per minute, pulse 160 beats per
minute, blood pressure of 140/60 mm. Hg. Art. Light hyperemia throat, the temperature during the
inspection 39,6º C.
Appointed:
S. Analgini 50% - 1.0 - intramuscularly.
S. Dimedroli 1% - 1.0 - intramuscularly.
S. Dibazoli 1% - 1.0 - intramuscularly.
Paracetamol 0,5h4 times a day.
Rich alkaline drinking.
Ascorutinum x 1 tablet 3 times daily
Tasks
1. Identify, meeting any requirements violated the patient's problems, their rationale.
2. Define the objectives and plan of nursing intervention with motivation.
3. Demonstrate the technique of oxygen therapy with nasal catheter.
4. Rules applying ice packs.
Standards of answers
1. Violated needs: to maintain normal body temperature, eat, sleep, talk, move, select, learn, be
healthy.
The problems of the patient:
True:
- Fever,
- Headache,
- Vomiting,
- Sleep disturbances,
- Concerns about the outcome of the disease;
Potential:
- Asphyxia vomit,
- The deterioration of conditions associated with the development of complications.
2. The priority concerns of the patient - a fever.
Short-term goal: to reduce the fever for the next five days to subfebrile figures.
Long-term goal: normalization of temperature at the time of discharge.
Plan Motivation
Nurse:
1. Will provide patient physical and psychological comfort. 1. To improve the condition of the patient.
2. Organizes individual nursing unit care patient. 2. To monitor the condition of the patient.
3. Provide abundant fluid intake (rich alkaline drinking for 2 days). 3. To prevent dehydration
4. hold a conversation with the relatives of providing additional power. 4. In order to compensate for
the loss of the protein and increase the body's defenses.
5. Measure your body temperature every 2 hours. 5. To monitor the condition of the patient
6. Applying the methods of physical cooling:
- Shielding sheet or light blanket.
- Use a cold compress or ice pack 6. To reduce body temperature
7. greased lip vaseline oil 3 times a day. 7. skin moisturizing lip
8. ensure receiving a liquid or semi-liquid food 6-7 times a day 8. To better digestion.
9. To ensure good care of the skin and mucous membranes of the patient. 9. For the prevention of
inflammatory processes of the skin and mucous membranes
10. Ensure change underwear and bed linen as needed. 10. To ensure patient comfort.
11. Will watch the appearance and condition of the patient. 11. For early diagnosis and timely
emergency care in case of complications.
12 will carry a doctor's prescription. 12. For the treatment of the patient.
Rating: patient reported a significant improvement in health status, body temperature is 37,4º C. The
objective will be achieved.
Problem №2
Active visiting nurse for the boy 4 years. Diagnosis: acute respiratory viral infections.
When nursing medical examination. sister received the following information: the child became ill to
eat, worried cough that intensified and has the character of dry, painful. In the words of my mother is ill
the second day. First there was a cold, cough, fever and then to 38,2º C.
Objectively: child active temperature 37,3º C, nasal breathing is difficult, mucus from the nasal passages.
Frequent dry cough, respiratory rate 28 per minute heart rate - 112 per minute, pharynx - moderate
hyperemia, no raids.
Prescribing:
- At temperatures above 38,3º paracetamol 0.2
- Complex nasal drops 3 drops 5-6 times daily, both the nasal passage.
- Distraction therapy.
- Cough mixture
Tasks
1. Identify, meeting any requirements violated the patient's problems, their rationale.
2. Define goals and make a plan of nursing intervention with motivation.
3. Educate mother technique of oil inhalation.
4. Demonstrate the technique of setting mustard plasters on the chest.
Standards of answers
1. Violated needs: eat, breathe, sleep, relax, socialize, to maintain normal body temperature, to be
healthy.
The problems of the patient:
True:
- Dry cough
- Ineffective airway clearance
- Fever
- Loss of appetite
Potential:
- Deterioration of the patient associated with the development of complications.
2. The priority concerns of the patient - a dry cough.
Short-term goal: the patient noted a decrease in the frequency and duration of cough at the end of the
week.
Long-term goal: the absence of coughing at the time of discharge.
Plan Motivation
Nurse:
1. Will provide a warm drink, do not irritate.
2. Will give the patient position Fowler.
3. To ensure the implementation of the simplest physical therapy (mustard, hot compress, mustard foot
bath) prescribed by a doctor. In order to change the nature of the cough and make breathing easier.
4. Provide patient inhalation (oil, eucalyptus, etc.) prescribed by a doctor.
5. hold a conversation with the relatives of the patient to provide additional power. To compensate for
the loss of the protein and increase the protective forces.
6. Ensure reception cold preparations prescribed by a doctor to reduce coughing.
Rating: the patient's condition has improved significantly, the frequency and duration of cough
decrease. The objective will be achieved.
Problem №3
A boy of 10 years is hospitalized. The diagnosis: rheumatism, active phase, polyarthritis.
When nursing examination nurse has received the following information: the boy complains of pain in
the left knee, because of the pain does not arise, can not change the position of the legs in bed. Prior to
that (3-4 days ago) worried about the pain in the right ankle. In history three weeks ago I was ill with
angina.
Objectively: temperature 37,8º C. skin is pale, clean, blue shadows under his eyes, a passive position in
bed. The left knee feels hot, round, increased in size, movement painful. Pulse - 100 beats per minute,
respiratory rate - 22 per minute.
Prescribing:
- Aspirin 0.5 x 4 times a day after meals,
- Ampioks intramuscularly 500 thousand. Units. x 4 times a day,
- Strict bed rest.
Tasks
1. Identify, meeting any requirements violated the patient's problems, their rationale.
2. Define goals and make a plan of nursing intervention with motivation.
3. Demonstrate the imposition of a cold compress on the area of the affected joint.
4. Educate the patient's rules aspirin.
Standards of answers
1. Violated needs: to move, dress and undress, to maintain body temperature, sleep, relax, be healthy.
The problems of the patient:
true:
- Limitation of physical activity
- Pain in the joint
- Fever
Potential:
- The risk of bedsores
- The risk of constipation
- Risk of disability associated with a deficit of rest.
2. The priority concerns of the patient - pain in the joint
Short-term goal: to reduce pain for 1-2 days.
Long-term goal: the patient will adapt to his condition and life in society at the time of discharge.
Plan Motivation
Nurse:
1. provide patients with physical and mental peace;
2. Provide forced position the patient in the bed;
3. to implement a set of measures for the care of the patient;
4. Ensure staging a cold compress on the area of the joint (by a doctor);
5. It will be the easiest to carry out complex physical therapy and massage (by a doctor);
6. hold a conversation with the family about the psychological support of the patient gently on his
physical activity;
7. hold a conversation with the patient about the inactivity and its consequences;
8. ensure compliance with doctor's appointments. 1. To improve the patient's condition.
2. In order to reduce the pain.
3. To comply with the rules of personal hygiene.
4. In order to reduce the pain.
5. To prevent inactivity and bedsore.
6. To facilitate the adaptation of the patient to his condition.
7. To prevent inactivity.
8. For the treatment of the patient.
Rating: the patient's condition has improved significantly, decrease joint pain. The objective will be
achieved.
Problem №4
In-patient treatment is a girl of 12 years. Diagnosis: acute glomerulonephritis, edematous form. When
nursing examination nurse has received the following information: complaints of general weakness,
poor appetite, headache, swelling of the face and legs. He considers himself a patient for 2 weeks when
first introduced these complaints. The history: frequent SARS, sore throat, dental caries. Objectively:
skin pale, pure, pasty face and legs. Pulse - 104 per minute, blood pressure - 130/80 mm. Hg. Art., RR 20 per minute. Belly regular shape, soft and painless.
Prescribing: strict bed rest, table number 7 in view of diuresis.
Tasks
1. Identify, meeting any requirements violated the patient's problems, their rationale.
2. Define goals and make a plan of nursing intervention with motivation.
3. Educate the patient's personal hygiene.
4. Control diuresis. The term "water balance".
Standards of answers
1. Violated needs: eat, drink, excrete, to be healthy.
The problems of the patient:
true:
- Swelling in the face and legs
- A violation of appetite
- Headache
- Weakness
Potential:
- The risk of deterioration of the patient associated with the development of complications.
Priority problem: swelling of the face and legs.
2. Short-term goal: to reduce the swelling in the face and legs at the end of the week.
Long-term goal: to demonstrate knowledge of the relatives about the features of nutrition and fluid
intake to discharge.
Plan Motivation
Nurse:
1. Explain to the relatives of the patient and to follow a diet with restriction of salt-rich protein and
potassium salts (table number 7);
2. provide verification programs;
3. to care for skin and mucous membranes;
4. Will every day to determine the water balance of the patient;
5. ensure control over the regime physiological functions of the patient;
6. Ensure patient warm vessel;
7. Ensure heaters to warm the bed;
8. Will the patient to weigh 1 time in 3 days;
9. Ensure the reception of medicines prescribed by a doctor. 1. For the prevention of complications.
2. In order to monitor compliance with the diet.
3. To comply with the rules of personal hygiene.
4. In order to control the dynamics of edema.
5. To monitor the dynamics of edema.
6. To improve the microcirculation.
7. To improve the microcirculation.
8. To monitor the dynamics of edema.
9. For the treatment of the patient.
Rating: the patient's condition improves, decrease swelling. The objective will be achieved.
Problem №5
Boy 10 years old, is hospitalized. Diagnosis: thrombocytopenic purpura. When nursing examination
nurse has received the following information: complaints of bleeding from the nose, which appeared a
few minutes ago (during the game). Pale skin, multiple hemorrhages in the form of spots of various
sizes, shapes, randomly arranged, different colors (red, blue, green, yellow). Bohlen 2 years, the
deterioration occurred in the last week (suffered SARS) were hemorrhages in the skin and oral mucosa.
It worries.
OBJECTIVE: conscious, oriented contacts. Pale skin, respiratory rate 22 per minute, pulse 112 per
minute, blood pressure 100/60 mm Hg
Tasks
1. Identify, meeting any requirements violated the patient's problems, their rationale.
2. Define the objectives and plan of nursing intervention with motivation.
3. Educate the patient stopping rules epistaxis.
4. Demonstrate the technique of the front nose tamponade.
Standards of answers
1. Violated needs: eat, drink, breathe, be healthy.
The problems of the patient:
true:
- Nose bleed,
- Anxiety,
- Bleeding in the skin.
Potential:
- The risk of complications.
2. The priority concerns of the patient - nosebleeds.
Short-term goal: to stop nosebleeds for 3 minutes.
Long-term goal: Relatives demonstrate knowledge about how to stop the nosebleeds at home.
Plan Motivation
Nurse:
1. to provide patients with a raised horizontal position head (not to throw back his head back);
2. provide patients a cold compress on the nose and back of the head;
3. Ensure the patient cotton tubes impregnated with 3% hydrogen peroxide solution in the nasal
passages;
4. provide patients physical and psychological peace
5. Ensure the implementation of doctor's appointments
6. hold a conversation with relatives
1. To prevent aspiration of blood.
2. vasoconstriction.
3. To stop the bleeding.
4. In order to improve the patient's condition
5. To treat a patient
6. To train health care when epistaxis.
Rating: nosebleeds stopped. The objective will be achieved.