Nursing Care Priorities and Medications for a Patient in a Care Setting

QUESTION

1. What is the primary problem that brought your patient to this care setting? What is the pathophysiology of this problem?
2. What vital signs/nursing assessments/lab-diagnostic test results are RELEVANT and need to be monitored and trended? Why are they relevant?
3. What body system(s) need to be assessed most thoroughly because of the primary problem? What specific nursing assessments are most important? Why?
4. What is the current nursing priority?
5. What independent nursing interventions (interventions that do not require an order/based on nursing judgement of patient needs) will you initiate based on this priority and what are the desired outcomes?
6. What is the worst possible/most likely complication(s) to anticipate based on the primary problem?
7. What will you do to PREVENT this complication from developing?
8. What nursing assessments will identify this complication EARLY if it develops?
9. What nursing interventions will you implement if this condition develops?

While Providing Care 

1. What current clinical assessment data is relevant and needs to be TRENDED? Based on your interpretation of current clinical data, what is your judgement regarding this patient’s current status?
2. Does your nursing PRIORITY or plan of care need to be modified after assessing your patient?
3. What educational, emotional, psychosocial, spiritual, or cultural care PRIORITIES have you identified and how will you address them?

After Patient Care…reflect on thinking 

1. What nursing interventions did or could you have delegated today?
2. What specific decisions or judgements did you make based on recognition and interpretation of relevant clinical data?
3. What would you do differently (if applicable)?
4. What did you learn as a result of making these judgements?
5. How will you apply what you learned making these judgements to patients you care for in the future?

Which medications would this patient be on and why?

ANSWER

Nursing Care Priorities and Medications for a Patient in a Care Setting

Introduction

In a care setting, nurses play a critical role in assessing, monitoring, and providing interventions to patients. This article addresses the nursing care priorities for a specific patient, focusing on the primary problem, relevant assessments, interventions, and potential complications. Additionally, an overview of the medications commonly used for this patient’s condition is provided, along with their rationale.

Primary Problem and Pathophysiology

The primary problem that brought the patient to the care setting must be identified to guide nursing care. The specific pathophysiology of the problem is crucial for understanding the underlying disease process, its manifestations, and potential complications.

Relevant Assessments and Monitoring

Vital signs, nursing assessments, and lab-diagnostic test results are relevant and should be regularly monitored to track the patient’s condition and detect any changes. They provide valuable information about the patient’s physiological status, response to interventions, and any potential complications.

Thorough Assessment of Body Systems

The body system(s) most affected by the primary problem should be assessed thoroughly. The specific nursing assessments will depend on the primary problem and associated symptoms. For example, if the patient has respiratory distress, respiratory assessments such as lung sounds, oxygen saturation, and respiratory rate will be crucial.

Current Nursing Priority

The current nursing priority is determined by the patient’s immediate needs and the severity of their condition. It may involve addressing acute symptoms, ensuring patient safety, or preventing complications.

Independent Nursing Interventions

Based on the identified priority, independent nursing interventions are initiated to address the patient’s needs. These interventions are based on nursing judgment and do not require a specific order. The desired outcomes should be specific, measurable, achievable, relevant, and time-bound (SMART goals).

Anticipated Complications and Preventive Measures

Considering the primary problem, the most likely complications should be anticipated. Proactive measures can be implemented to prevent these complications from developing, including patient education, close monitoring, and timely interventions.

Early Identification of Complications

Specific nursing assessments can help identify complications early, enabling prompt intervention. These assessments may include ongoing vital sign monitoring, close observation of symptoms, and regular evaluation of lab-diagnostic results.

Nursing Interventions for Complications

If a complication develops, specific nursing interventions should be implemented to address the condition promptly and effectively. These interventions are tailored to the specific complication and may involve collaboration with other healthcare professionals.

Relevant Clinical Data and Patient Status

Relevant clinical data should be trended to monitor the patient’s progress over time. Based on the interpretation of current clinical data, the nurse can make a judgment regarding the patient’s current status and determine whether any modifications are needed in the nursing priority or plan of care.

Addressing Educational, Emotional, Psychosocial, Spiritual, and Cultural Care Priorities

Nursing care extends beyond physical needs. Educational, emotional, psychosocial, spiritual, and cultural care priorities must be identified and addressed to provide holistic patient-centered care.

Delegation of Nursing Interventions

Some nursing interventions may be delegated to other healthcare team members based on their scope of practice and competence. Delegation promotes effective utilization of resources and ensures efficient delivery of care.

Decision Making and Learning

Throughout the care process, nurses make decisions and judgments based on recognition and interpretation of relevant clinical data. Reflecting on these decisions, learning occurs, and adjustments can be made to improve future patient care.

Medications

The specific medications prescribed for this patient will depend on the primary problem and associated comorbidities. Common medications may include analgesics for pain management, antibiotics for infections, and specific medications to address the underlying disease process or symptoms. The choice of medications is based on evidence-based practice, the patient’s condition, and individualized treatment goals.

Conclusion

Nursing care in a clinical setting is multifaceted and requires a systematic approach to address the primary problem, prevent complications, and provide holistic care. By identifying the primary problem, conducting relevant assessments, implementing appropriate interventions, and monitoring the patient’s progress, nurses can optimize patient outcomes and ensure their well-being. Additionally, addressing educational, emotional, psychosocial, spiritual, and cultural care priorities contributes to comprehensive patient-centered care. By continuously learning from clinical experiences and making informed decisions, nurses can apply their knowledge and judgment to future patient care, promoting ongoing professional growth and improved patient outcomes.

In terms of medications, the specific drugs prescribed will depend on the patient’s primary problem and associated conditions. The choice of medications aims to manage symptoms, treat underlying diseases, and improve the patient’s overall well-being. Nurses play a crucial role in administering medications, monitoring their effectiveness, and educating patients on proper usage and potential side effects. The selection of medications is based on evidence-based practice, individual patient needs, and the guidance of healthcare professionals involved in the patient’s care.