Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

Subjective:

Client expressed she didn’t want to move “anymore than she has to.”

Hx of DM II, CAD

Objective:

Temp:  101.0

Basilar rales bilaterally

Elevated BP (145/86)

Elevated HR (110)

Client is in atrial fibrillation w/ rapid ventricular response

EKG findings of inferior infarction and left axis deviation

Decreased grips/weakness on left side

Decreased urine output (0 ml/10 hours)

Elevated potassium level of 5.3

Elevated BUN (41)

Elevated Creatinine (1.73)

2x3, 1 inch depth stage II ulceration on coccyx

Unstageable ulceration on right heal

Presence of multiple tears on upper extremities

Client is NPO

Elevated blood glucose (185)

Post-CVA

Problem

Impaired skin integrity

Long Term:

Client will regain integrity of skin surface by Month 15, Year, 16:00.

-Monitor site of skin impairment at least once a day for color changes, redness, swelling, warmth, pain or any other signs of infection.  Pay special attention to high risk areas and question client to determine whether she is experiencing loss of sensation.  Systematic inspection can identify impending problems early (Ayello & Braden, 2002).

-Do not position client on site of impairment, turn and reposition q 2 hours, use careful transfer technique to reduce risk of injury from mechanical sources.

-Facilitate consultation with nutritionist.  Optimizing nutritional intake is needed to promote wound healing (Russell, 2001).

R/T

Hyperthermia, mechanical factors, physical immobilization, changes in fluid status, impaired metabolic state, and impaired circulation.

Short Term:

Client demonstrate understanding of plan to heal skin and prevent re-injury via verbalization by[Month] 15, [Year], 14:00.

-Assess current level of knowledge r/t treatment regimen.

-Teach client the treatment regimen, exercise goals and plan, and medication regimen along with actions and side effects.

-Teach skin and wound assessment and ways to monitor for s/s of infection, complications and healing.  Early assessment and interventions may help complications from developing ((Ackley & Ladwig, 2008)

AEB:

Left side extremity weakness, right side hemiparesis, altered BP outside of acceptable parameters, oliguria (0 ml/10 hr), elevated BUN (41), elevated creatinine (1.73), dysrhythmias, altered respiratory rate (24) and presence of 2x3, 1 inch depth stage II ulceration on coccyx, unstageable wound on the right heal, presence of multiple skin tears on the upper extremities, decreased Hgb (10.2), decreased albumin (2.0), elevated blood glucose (185) and client is NPO.