Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective:

During discussion of blood sugar levels, client wouldn’t make eye contact or answer questions about what she had eaten recently.

Objective: 

Client was observed asleep with hand in a 1/4^th full bag of candy.  A liter of Dr. Pepper was observed on the bedside table, ½ full.  Client’s blood sugar progressively elevated from 278 to 445 by shift’s end.

Problem:  Noncompliance

Long Term:

Client will list treatment regimens and expectations and agree to follow through by 22:00 [Month] 17, [Year].

Make the client an active partner in her own healthcare management.  Treat her with respect and acknowledge her autonomy.  Recognize the client has ultimate control over whether she follows the regimen.  If the client feels respected and involved in decision making, compliance will be increased  (Tsoneva & Shaw, 2004).

*

Evaluation of this goal is set for 22:00, [Month] 17, [Year].  Client was medicated from pain and became too confused to discuss treatment goals, regimens and expectations.  No progress towards goal made.  

Evaluation of this intervention is set for 22:00, [Month] 17, [Year].  Attempted to discuss treatment regimen and expectations with client.  Medication side effects rendered the discussion useless.  Goal not achieved, secondary attempt required in between medication administrations. 

R/T:

Duration of therapeutic regimen

Short Term:

Client will describe the consequences of continued noncompliance with the treatment regimen by 22:00 [Month] 10, [Year].

Ask the client why she has not complied with the treatment regimen.  Have the client tell her story.  Listen nonjudgmentally, assessment should begin with a non-threatening discussion.  Clients reported how they were treated by healthcare professionals has a great impact on whether they will follow advice (Tsoneva & Shaw, 2004). 

*

Client indicated she didn’t feel good and wanted sugar to make her feel better.  Client also indicated “I need to get my blood sugar up…it’s too low.”  Medication administration and resultant confusion may have contributed to client’s noncompliance. Client was unable to describe consequences.  Goal not achieved.  Secondary attempt should be made by [Month] 11, [Year].

Described the consequences of noncompliance with the client at 11:30 on [Month] 10, [Year].  Client was in a confusional state related to medication, reeducation is required.  No progress towards goal.  Secondary attempt should be made by 8:00 [Month] 11, [Year].

AEB:

Consumption of candy with a blood sugar of 408, and verbalization of understanding that a controlled carb diet was ordered.

Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective:

Client indicated pain was an “8” on a scale of 0-10.  Client indicated pain was aching, throbbing and persistent.  Client indicated nausea, shielded eyes with hands, and appeared restless.

Objective: 

Client was distracted and answered questions in brief “yes,” “no” fashion, different from previous discussions.  Client presented with pallor. 

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:

Physical and biological injury agents and advanced disease process.

Short Term:

Client will express relief from pain within 30 minutes of medication administration. 

Client will describe past experiences with pain and effectiveness of methods used to manage pain, including experiences with side effects.

Client will communicate a comfort-function goal. 

-Assess current pain level.  The client’s self report is the single most reliable indicator of level of pain  (APS, 2004).

-Assess location of pain

-Administer medication as ordered

-Reassess pain level to ascertain relief level achieved

-Discuss with client past experiences with pain and effectiveness of medications and side effects.

-Discuss with client comfort-function pain level.  Attempt to keep client within that level to maintain functionality and ADLs .  The pain rating that allows a client to have appropriate function should be determined to allow a measurable method of outcomes of pain management  (Griffie, 2003).

*

Client indicated relief from pain within 30 minutes of medication administration .

Client describe past experiences with pain, effectiveness of treatment methods and a level at which she could perform ADLs (6 on a scale of 0-10).

Goal achieved.

Assessed client’s pain throughout the day. 

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

Discussed patient’s past experiences with pain medications, the side effects and pain level appropriate for performing ADLs.

These goals achieved.

Not achieved:  client’s pain management not within range that allowed her to have appropriate cognitive or physical functioning.  Reevaluation of this intervention set for 11:30 [Month] 17, [Year].

AEB:

Patient self-assessment of pain rated an 8 on a scale 0f 0-8, generalized pallor, self-report of nausea r/t pain quality, restlessness, and distractibility.