APPLICATION OF NURSING PROCESS

Instruction: Read the situation below and answer the following questions.

SITUATION: Brenda Page is a 51 year old woman, working as a senior accountant. She is divorced with two children and is now living alone in her condominium but she has a good relationship
with her 2 children that visits her often. One year ago, she felt a nodule on her right breast near the mid axillary area but ignored it. Recently, she experienced pain on that area and the skin on
top of that region has an enlarge pores with inflammation manifested by redness and firm surroundings. She sought consultation and referred for biopsy as was diagnosed of Stage 2 Breast
cancer. Ms. Brenda, underwent modified radical mastectomy and was referred for a cycle of radiation and chemotherapy. During confinement, you are the nurse assigned to her during her 2nd
day post-operative recovery. You assess the patient and was able to get the following information: She stated that “I’m ok, it’s just that my wound is really painful specially when I’m moving.
Can you do something about it?”, “I am just so lucky that my children are here to support me all the time”, patient is sweating with facial grimace while holding on the operative site. She rated
the pain 8/10 according to pain rating scale. She is warm to touch and a bit confused with the following Vital signs: BP: 130/80 mmHg, RR- 23 bpm, PR 108 bpm and Temperature of 38.2 degree
Celsius, Oxygen Saturation of 93% with good capillary refill. Further assessment shows that the operative site is inflamed with mild redness, no pus noted.

Answer the following Questions:

1. What is the type of Pain according to cause? _____________________________(2 points)
2. What is the type of Pain according to duration? __________________________ (2 points)
3. What is the type of Pain according to Location? __________________________ (2points)
4. Write at least 3 nursing problems/diagnosis based on the situation. (3 points each)
a. ____________________________________________________
b. ____________________________________________________
c. ____________________________________________________
5. Create a Nursing care plan of the 2 identified Nursing diagnosis above using the format below basing on the situation above. (50 points for each NCP)
NURSING CARE PLAN: Use an extra sheet if necessary.
ASSESSMENT/ NURSING EXPLANATION OF THE PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS PROBLEM
(Explain why the patient Instruction: Create a Goal All interventions should be Write the reason/purpose Since we don’t have an
SUBJECTIVE DATA: (if has or why the patient is Plan base on client’s geared to address the of the intervention. Should actual patient to get an
there is one) experiencing the nursing condition and nursing nursing problem and be written parallel to the actual response. Write an
problem) diagnosis/problem. should be able to achieve intervention. example of a possible
OBJECTIVE DATA your short and long term evaluation you will observe
SHORT TERM: goals. to patient experiencing
such nursing problems.

LONG TERM:

NURSING DIAGNOSIS:
Should either be 2 or 3
words nursing diagnosis
except for the stand-alone
1 word nursing diagnosis.