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									NURSING PROCESS

     Diagnosis
Identify the correctly written
          diagnoses
 High risk for injury related to unstable
  gait and dizziness
 Anger related to death of sister
 Disuse syndrome related to immobility
 Stress incontinence related to
  involuntary loss of urine with coughing
    Identify the phase of the
        nursing process
 While walking Mrs. Woolsey to the
  bathroom, she complains of dizziness:
 Ask her if the dizziness is related to an
  activity
 Take her blood pressure in lying and
  standing positions
 Determine what interventions will
  reduce her dizzines
     Identification (cont’d)
 Later, in the day, check with her if
  additional episodes have occurred
 Teach her to change her position slowly
 Formulate the nursing diagnosis “High
  Risk for Injury related tovertigo
  secondary to postural hypotension”
     Identification (cont’d)
 Mr. Todd has not been drinking enough
  fluids. He drank 600 mL from 7 a.m. to
  7 p.m. You:
 Asking him why he is drinking so little
 Formulate the diagnosis “Fluid Volume
  Deficit related to fatigue and decreased
  desire to drink”
     Identification (cont’d)
 Establish a fluid intake goal with Mr.
  Todd for each 12 hr. shift
 The next day, review his 24 hr. fluid
  intake, output, and specific gravity
 Teach him how to record intake and
  output
 Explain why inadequate hydration is a
  problem
EVALUATION ACTIVITY

  Phase of the nursing process
        Learning exercise
 Mrs. Vernon is unconscious after a
  cerebral vascular accident (stroke).
  Presently she has no evidence of
  pressure ulcers but is at high for
  developing pressure ulcers.
 Which of the following goals is the most
  helpful to evaluate this nursing
  diagnosis?
    Learning exercise (cont’d)
 Will be turned at least every 2 hrs.
 Will be free of incontinence
 Will continue to demonstrate skin free
  of pressure ulcers

								
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