The nursing process is a systematic method used by nurses to provide patient care. It consists of five key steps: assessment, diagnosis, planning, implementation, and evaluation. Let's apply this process to a patient with known Diffuse Proliferative Glomerulonephritis (DPGN) who presents with swelling in the lower left leg lasting for one week.
1. Assessment
The assessment involves gathering data about the patient:
- Health History: Obtain a comprehensive history of the patient’s DPGN, previous symptoms, current medication, and other relevant medical history.
- Physical Examination:
- Inspect the left lower leg for swelling (edema), redness, or tenderness.
- Measure the circumference of the lower legs to assess the degree of swelling.
- Check for signs of complications such as skin changes or ulceration.
- Assess vital signs, focusing on blood pressure (could indicate fluid overload).
- Laboratory Tests: Review lab results (e.g., urinalysis, serum creatinine, and electrolytes), looking for signs of renal function decline and proteinuria.
2. Diagnosis
Based on the assessment, identify nursing diagnoses. Potential nursing diagnoses for this patient might include:
- Excess Fluid Volume related to kidney dysfunction and possible nephrotic syndrome.
- Impaired Skin Integrity related to edema and potential skin breakdown.
- Risk for Impaired Comfort related to swelling and possible pain.
- Knowledge Deficit regarding the disease process and management.
3. Planning
Developing a care plan includes establishing goals and outcomes. Goals might include:
- The patient will demonstrate reduced edema in the left lower leg within 48-72 hours.
- The patient will verbalize understanding of dietary restrictions and medication compliance by discharge.
- The patient will maintain skin integrity with no signs of breakdown.
4. Implementation
Nurse interventions for this patient might include:
- Administer Medications: As prescribed (e.g., diuretics to reduce fluid overload, antihypertensives, or corticosteroids if indicated).
- Monitor Vital Signs: Regular monitoring for changes in blood pressure and heart rate.
- Assess Edema: Regular assessment of the degree of edema and measuring leg circumference.
- Teach: Provide education on dietary modifications (e.g., low sodium diet) and the importance of adhering to medication regimens.
- Positioning: Encourage the patient to elevate the affected leg to reduce swelling.
- Skin Care: Implement measures to maintain skin integrity, including regular inspection of the skin, moisturizing, and avoiding any irritants that may lead to breakdown.
- Fluid Management: Encourage adherence to fluid restrictions if prescribed.
- Referral: If necessary, consult with a dietitian regarding dietary modifications or a nephrologist for specialized care.
5. Evaluation
Evaluate the effectiveness of the nursing interventions and adjust the care plan as needed:
- Assess if there is a reduction in the swelling of the left leg.
- Re-assess vital signs and any potential discomfort.
- Determine if the patient has improved knowledge regarding their condition and care.
- Monitor for any complications, such as skin breakdown or changes in renal function.
Using this structured approach ensures that care is delivered systematically and effectively, focusing on the patient's needs and adjustments to their health status.