Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective:

Client has expressive aphasia and was unable to communicate subjective information r/t verbal communication.

Objective: 

The right lower hemisphere of the patient’s face is flaccid.

Problem:  Impaired verbal communication

Long Term:

Client will express desire for social interactions by 17:00 [Month] 10, [Year].

Use presence, spend time with the client and allow time for communication and understanding.  Leave the call light within reach.  Time with the nurse has a positive effect on the healing process and recovery  (Carroll, 2002)

*

Evaluation of this goal is set for 17:00, [Month] 10, [Year].  Client was making eye contact, utilizing notebook and pen to communicate, and waved goodbye at the end of the shift.  Progress made towards goal.  

Evaluation of this intervention is set for 17:00, [Month] 10, [Year].  Spent several hours with the client to establish relationship and communication methods.  Some progress toward goal. 

R/T:

Right side facial muscle paralysis, and damage to Wernicke’s area of the temporal lobe subsequent to a stroke.

Short Term:

Client will use an alternate means of communicating (picture page) common requests at least twice within 6 hours.

Identify common patient requests and create a visual aid to facilitate communication and decrease patient frustration.

Teach client use of picture page.

Communication technology enables humanness  (Dickerson et al., 2002)

*

Client utilized picture page to request pain medication, diet coke, ice and repositioning in bed on several occasions throughout the shift.  Client made requests (via writing in notebook) for additional pictures to be added to represent additional requests.

Goal achieved.

Identified four common requests:  Repositioning, pericare, Diet Coke and medication for pain.  Created a picture page with those requests and demonstrated its use.  The client utilized the picture page throughout the day.  In addition, client requested additional items added to the picture page. 

Goal achieved.

AEB:

Verbalization of “t-t-t-t….” to gain attention, inability to form words with meaning, crying when attempts to communicate needs fail, using a pen and paper to write single word requests, nonverbal expressions of frustration (throwing hand in the air, throwing pen, turning head away).

Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective:

Client does not communicate verbally.  When asked if  she was in pain, she pointed to her head, her right arm, and nodded.

Objective: 

The patient’s right arm was edematous and warm to the touch.  Her blood pressure was 120/59 (elevated for this patient).

Problem:  Acute pain

Long Term:

Client will function on acceptable ability level with minimal interference from pain and medication side effects.

Tell the client to report pain location, intensity, and quality when experiencing pain.  Assess and document the intensity of pain with each new report of pain and at regular intervals.  Systematic, ongoing assessment and documentation provide direction for the pain treatment plan  (APS, 2003)

*

Evaluation of this goal is set for 17:00, [Month] 10, [Year].  Client was using picture page to indicate need for pain medication, indicated relief after medication. Progress made towards goal. 

Evaluation of this intervention is set for 17:00, [Month] 10, [Year].  Assessed medication need, assessed pain level before and after.  Documented need for medication and relief from pain.  Some progress toward goal. 

R/T:

Right side hemiparesis and resultant dependent edema, inability to reposition without assistance, and inability to communicate pain levels and sources effectively.

Short Term:

Client will use an alternate means of communicating (picture page) to indicate need for pain medication within 6 hours. 

Client will demonstrate relief from pain by nodding head affirmatively within 30 minutes of medication administration.

-Create a visual aid to facilitate communication of pain.

-Teach client use of picture page.

Communication technology enables humanness  (Dickerson et al., 2002)

-Assess location of pain

-Administer medication as ordered

-Reassess pain level to ascertain relief level achieved

*

Client utilized picture page to request pain medication, on several occasions throughout the shift. 

Client indicated relief from pain within 30 minutes of medication administration (and BP dropped to 94/43).

Goal achieved.

Created a picture page with pain medication requests as an option and demonstrated its use.  The client utilized the picture page throughout the day. 

Assessed location of pain, facilitated medication administration and reassessed pain level after medication administration.

Goal achieved.

AEB:

Verbalization of “t-t-t-t….” to gain attention, tapping arm, tapping head repeatedly.  Elevated BP from norm for this client.  Client was listless, exhibiting fatigue and grimacing.