Sample Nursing Paper on Nursing Care

Assessments

Head   

It includes inspection of; face, skin, hair, scalp and skull. Inspect the skull and face (especially if the patient is complaining of tenderness. Assess facial sensation and motor functions)

Nose

Note any deformities or asymmetry of the nose .Examine the anterior snares by lifting the tip of the nose up and looking inside. To check patency, ask the patient to sniff or block one nostril while the patient sniffs. Note colour of nasal mucosa discharge.

Mouth /Throat

Throat exam is through the oral cavity. Inspect the oral mucosa for ulcers, color and gum erythema and edema .Note the tongue condition through pressing it down by use of a tongue depressor. It also helps to examine the uvula which should look like a pendant in the middle along the soft palate. Soft palate is checked with a pen light and should be pink smooth and movable in an upward motion. Abnormal findings in the uvula and soft palate include any of them being red and asymmetrical rise. The diseases may include bifid uvula, cleft palate and if the cranial nerve 10 is traumatized there is no rising of soft palate

Neck

Inspection for scars or nodular enlargement- Ask the patient to swallow to inspect thyroid gland .Palpate lymph nodes noting their size shape mobility and tenderness

Other assessment

Tonsils-Tongue is depressed to enable easy view of tonsils which are pink symmetrical and normal in size. Abnormal findings will include; red, enlarged tonsils with yellow or white exudate.

Medical records

All histories of;

Demographic data – includes patients name, age sex, phone number, residence, op number.

Medical  – chief complaint, history of present illness, physical exam (vital signs exam of different organ systems and diagnostic data)

Surgical

Family/medical

Social-(habits, exercise, diet and religion/culture)

Consent form

Physician orders – (test and treatments)

Nursing care plan

Assessment Nursing diagnosis Outcome Intervention Rationale
Cough Ineffective airway clearance related to inflammatory process evidenced  by cough Maintain  airway patency Monitor client ability to cough effectively Ineffective cough  compromises airway clearance and prevent mucus from being expelled
impaired feeding acute pain on jaws related to inflammatory process evidenced by patient report Patient to verbalize of pain relief Perform a comprehensive assessment of pain Through assessment we ensure patient receives effective pain relief

 

Client education – drug adherence

                              – coughing techniques

-oral care

-follow-up

 

Strategy- demonstration

                –Evaluation through follow-up assessment

 

 

 

Conclusion

Nursing care is the backbone of all nurses’ daily activities essential tools include assessment and physical examination to come up with an accurate and reliable nursing diagnosis .Through nursing care plan, patients problems are arrived at and dealt to the satisfaction of the patients.

 

References

Craven ,H.(Ed.) (2016).Core Curriculum for Medical-Surgical Nursing .(5th ed.) Pitman,  NJ: Academy  of

Medical-Surgical Nurses.

Roberts, D. (Ed.).(2014).Medical-Surgical Nursing Review Questions (3rd ed.). Pitman ,NJ: Academy of

Medical Surgical Nurses.