1.

Assessment Nursing Planning Nursing Rationale Evaluation

Diagnosis Intervention

2.
Assessment Nursing Planning Nursing Rationale Evaluation
Diagnosis Intervention

Subjective Data: Compromised After 3 days Independent: Goal met, after 3

family coping of nursing Assess family’s Knowledge days of nursing
*According to related to, intervention knowledge of will enhance intervention family
the patient’s progressive family patient’s the family’s members achieved
family member, dependence of members will disease and understandin increased coping
patient started the patient on achieve erratic g of the ability concerning
having memory the family as increased behaviors, and dementia patient’s AD and care
problems in evidence by coping ability possible violent associated needs.
2002, which unsatisfactory concerning reactions. with the
worsened results of patient’s AD disease and
significantly after attempts to and care development
his CABG and assist patient. needs. of coping
AVR in 2004. skills and
strategies.
*When patient
and his wife Provide for Promotes
returned four opportunity for venting of
weeks later. The family to feelings and
wife reported express reduces
complete concerns and anxiety.
resolution of the lack of control
symptoms, and of situation.
the patient
denied feelings Instruct family Assists family
of depression, and to prevent
stating “I am a demonstrate injury or
happy man.” time-saving, accident to
energy- patient or
*Patient stated conserving themselves.
that he was techniques to
depressed be used to
because he was assist patient.
worried about Provides
his memory Instruct family information
problems. regarding and support
community from those
Objective Data: resources people that
 available for understand
*The patient’s AD, their and
Mini-Mental families, as well empathize
State as utilization of with these
Examination respite care. families.
(MMSE) was Respite care
16/30. may help
facilitate
*Cornell Scale caregiver’s
for Depression in sense of well-
Dementia was 8 being. Some
for the patient. families may
feel that
The patient was asking help
started on 25mg from others
PO qD of a indicates lack
Selective of caring for
Serotonin the patient.
Reuptake
Inhibitor (SSRI)
which was
increased to
50mg PO qD
after one week.

3.
Assessment Nursing Planning Nursing Rationale Evaluation
Diagnosis Intervention

Objective Data: Chronic pain After 3 days Independent: Goal met, after 3
*84 year old related to, of nursing days of nursing
white female chronic intervention Explore the Analgesic intervention the client
with physical the client will need for combinations was able to
osteoporosis, dissability. be able to medications may enhance demonstrate
lumbar demonstrate from the three pain relief. behavioral
compression behavioral classes of modifications of
fractures, modifications analgesics: lifestyle and
chronic pain of lifestyle opioids appropriate use of
Giant Cell and (narcotics), therapeutic
Arteritis appropriate non-opioids interventions.
(GCA)/Polymaya use of (acetaminophe
lgia rheumatica therapeutic n, Cox-2
(PMR) treated interventions. inhibitors, and
with steroids nonsteroidal
since 2001. anti-
inflammatory
Depression drugs
since death of [NSAIDs]), and
spouse 2001 adjuvant
medications.
Colo-vesicular Opioid doses
fistula since Obtain should be
10/02 prescriptions to adjusted
increase or individually to
DM, HTN decrease achieve pain
CHF, COPD analgesic relief with an
PAF, doses when acceptable
hypothyroidism indicated. Base level of
prescriptions on adverse
the patient’s effects.
List Medications: report of pain
• Metoprolol SR severity and the
25 mg qd comfort/functio
• Furosemide 80 n goal and
mg qd response to
• KCl 80 mEq qd previous dose
• Prednisone 10 in terms of
mg qd relief, side
• Alendronate 70 effects, and
mg qweek ability to
• Calcitonin NS perform the
200 IU qd daily activities
• Ca/D 500/200 and the
TID prescribed
• Morphine SR therapeutic
30 mg BID regimen.
• Morphine IR 5
mg q4h prn Educate patient One of the
• NPH insulin18 of pain most
• Mirtazapine 15 management important
mg qhs approach that steps toward
• Warfarin 2mg has been improved
qhs ordered, control of
• Senna 2 tabs including pain is a
qhs therapies, better patient
• Colace 100 mg medication understandin
BID administration, g of the
• L-thyroxine 50 side effects, nature of
mcg qd and pain, its
• Ranitidine 150 complications. treatment,
mg qd and the role
• Albuterol nebs patient needs
• Ipratropium to play in pain
MDIqAM/12 control.
qPM
 Implement Nonpharmac
nonpharmacolo ological
gical interventions
interventions should be
when pain is used to
relatively well reinforce, not
controlled with replace,
pharmacologica pharmacologi
l interventions. cal
interventions.

4.
Assessment Nursing Planning Nursing Rationale Evaluation
Diagnosis Intervention

Objective Data: Potential for After 3 days Independent: Goal met, after 3
fluid volume of nursing Assess vital 1. To days of nursing
Patient’s Medical deficit intervention signs and establish a intervention client
History: client will be monitor I&O. baseline of was able to maintain
*high blood able to patient. adequate fluid
pressure maintain volume.
*CAD adequate fluid Administer To see if
*congestive volume. clear fluid to fluids are
heart failure patient. retained, in
*cataracts order to stop
*hearing IV.
impairments
*knee Teach patient The patient
osteoarthritis the will know
complications when to call
Medications: of fluid volume the health
lisinopril, deficit (Linton provider.
furosemide, 295).
ASA, and
metoprolol Collaborative:

Patient has Administer IV To keep

abdominal fluids as fluids in the
distention, ordered. patient.
hypoactive (simulation).
bowel sound and
no mass is
found. Her heart
is enlarged and
no S3.

Laboratory
Findings:
WBC-13290
HCT-42
Na-128
K-2.6
Bun/creatinine-
normal

5.
Assessment Nursing Planning Nursing Rationale Evaluation
Diagnosis Intervention

Subjective Data: Impaired skin After 3 days Independent: Goal met, after 3
integrity of nursing days of nursing
83 yo woman related to intervention Assess skin for Open skin intervention client
complaining of altered client will be lesions. Note lesions was able to verbalize
pruritic “hives” circulation; able to presence of increase the feelings of increased
one day ago on sensation; verbalize excoriations, patient’s risk self-esteem and
trunk and thighs pigmentation feelings of erosions, for infection. ability to manage
accompanied by increased fissures, or Thickening situation.
nausea and self-esteem thickening. occurs in
lightheadedness. and ability to response to
manage chronic
Objective Data: situation. scratching
(lichenificatio
Past Medical n).
History:
Osteoarthritis: Identify Patients may
hip arthroplasty aggravating develop
10/04 factors. Inquire dermatitis in
Osteoporosis about recent response to
Labyrinthitis changes in use changes in
Colon cancer of products their
stage II: 2000 such as soaps, environment.
laundry Extremes of
Medications: products, temperature,
fluoxetine (10mg cosmetics, wool emotional
daily) or synthetic stress, and
fosamax (70mg fibers, cleaning fatigue may
weekly) solvents, and contribute to
MVI daily so forth. dermatitis.

Physical Encourage the

Examination: patient to avoid Some change
aggravating in lifestyle
BP: 150/68 (not factors. may be
orthostatic) indicated to
Cardiac: regular reduce
rate in 80s, triggers.
normal exam
Skin: patch of Encourage the
erythema on patient to adopt One of the
back and trunk skin care first steps in
beneath bra routines to the
strap, erythema decrease skin management
over beltline, red irritation of dermatitis
papules on lower is promoting
anterior chest, healthy skin
ecchymoses on and healing
shoulders and of skin
legs. The rash lesions.
seen on exam is Collaborative:
different than the
transient rash Prepare the
that she had one patient for This
day ago. phototherapy or treatment
photochemothe modality uses
rapy. ultraviolet A
or B light
waves to
promote
healing of the
skin. The
addition of
psoralen,
which
increases the
skin’s
sensitivity to
light, may
benefit
patients who
do not
respond to
phototherapy
alone.