Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective:

Client stated, “I am really tired lately and keep having these pains come and go.”

Objective: 

-Hemoglobin level is below normal at 8.8

-Hematocrit is below normal at 29.0

-Platelets are elevated at 517

-WBC are normal, but have been steadily decreasing (from 8.1 to 6.2) since admission

-Client’s blood tests reveal MRSA colonization

-Client has several invasive medical interventions including a colostomy, a Foley catheter and an IV insertion in the left antecubital space.

-Slightly elevated glucose of 111

-A low serum albumin level of 2.9

-A slight low aPTT of  24.3

-client is on a liquid diet

-client is 78

-client is on aspirin,

Problem:  Ineffective protection

Long Term:

Client will remain free of infection during the duration of this hospital visit.

-Observe and report signs of infection such as warmth, redness, discharge and increased body temperature.  Surveillance for nosocomial infection should include fever of unknown origin as the single most common and clinically important finding for detecting infection  (Englehart,et. al 2002)

-Use strategies to prevent infection transmission including washing hands before and after client contact and wearing gloves during any contact with body fluids, and changing gloves in between contacts of various systems (i.e. GU, oral mucosa, etc.).  Meticulous infection control precautions are required to prevent the transmission of infectious organisms (Gould, 2004).

*

Evaluation of this goal is set for 22:00,[Month] 10, 2009.  Client was free of signs/symptoms of infectious processes throughout the shift, some progress made.

-Observed client for signs and symptoms of infection including fever, warmth, redness, and discharge.  -Washed hands before and after all client contact.  Wore gloves during all care that had potential for contact with body fluids and changed them in between contact with body systems where body fluid could be transferred to minimize risk of infection. 

Client showed no signs of infection.  Some progress towards goal made.  Continue interventions.

Evaluation of this goal set for [Month] 10, 2009 at 22:00.

R/T:

related to a bleeding disorder , inadequate nutrition, extremes in age, impairment of primary defenses and  medical interventions

Short Term:

Client will state symptoms of infection (fever, redness and/or warmth at IV site, burning around Foley catheter site, warmth and/or redness or irritation at the colostomy site) of which to be aware and monitor for by 13:00 on [Month] 3, 2009.

-Assess client’s current level of knowledge r/t infection s/s

-Seek teachable moments to encourage health promotion.  The provision of information should not be restricted to just treatment information but also any information that prepares the client to manage health-related issues (Timmons, et. al 2006)

-Teach client the signs and symptoms of infection both generalized and local by invasive site (i.e. fever being generalized and localized redness and irritation at the IV site).  Education programs based on empowerment, client participation, and adult learning principles have demonstrated effectiveness (Kennedy, et. al, 2003).

*

Client stated the symptoms of infection to monitor for at 11:15 on  [Month] 10, 2009.  Goal achieved.

At 11:00 on [Month] 3, 2009 assessed client’s current level of knowledge related to signs and symptoms of infection of which she stated, “fevers, throwing up and not feeling good.”

Sought teachable moments to encourage health promotion, provided education on nutrition and easy meals to freeze and make at home.

Taught client the generalized and localized signs and symptoms of infection to monitor for both within the hospital and at home.

Goal achieved.

AEB:

 Low serum hemoglobin, low serum hematocrit, low serum albumin, and increased serum platelet count and a current MRSA infection.

Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective:

Client indicated intermittent periods of pain that radiates from her stomach to her chest.  Client stated, “I’m pretty tired these days.”  Client also stated, “I get really out of breath going up and down stairs from my heart problem.”

Objective: 

-Serum BNP was 585

-Serum troponin was elevated at 0.12

-Electrocardiogram showed a mitral valve regurgitation, tricuspid valve regurgitation and aortic valve regurgitation, all “mild.”

-Client’s lower extremities have no hair and the pulses are 1+ and equal bilaterally in the posterior tibialis region

-client has

Problem:  Ineffective tissue perfusion:  gastrointestinal, peripheral arterial and cardiopulmonary systems

Long Term:

Client will demonstrate adequate tissue perfusion as evidenced by palpable peripheral pulses, warm and dry skin, adequate urinary output and absence of chest and abdominal pain by 13:00 [Month] 10, 2009.

-Assess tissue perfusion by monitoring radial, brachial, popliteal, dorsalis pedis and posterior tibialis pulses.

-Assess for episodes of acute pain using a 0-10 pain scale.

-Palpate skin in both upper and lower extremities to assess skin temperature and identify changes

-Monitor I&O

*

Client demonstrated adequate tissue perfusion throughout the shift and reported no pain in her chest or abdomen.

Goal partially achieved, further monitoring required.

Interventions were successful at monitoring for adequate tissue perfusion.

Continued evaluation of this intervention is set for 13:00, [Month] 10, 2009. Intervention successful to date.  Further evaluation required.

R/T:

GI: tubular growth extended from the pancrease to the biliary duct of the gallbladder

Peripheral arterial:  decreased hemoglobin concentration in the blood

Cardiopulmonary:  Altered preload, impaired transport of oxygen

Short Term:

Client will identify changes in lifestyle needed to increase tissue perfusion by 13:00 on [Month] 3, 2009.

-Assess client’s peripheral pulses

-Keep the client warm and have them wear socks.  Clients with arterial insufficiency report extremities being constantly cold, keeping extremities warm maintains vasodilation and blood supply (Ackely et. al, [Year]).

-Assess patient’s current level of knowledge r/t increasing tissue perfusion.

-Seek teachable moments to encourage health promotion.  The provision of information should not be restricted to just treatment information but also any information that prepares the client to manage health-related issues (Timmons, et. al 2006).

-Teach client the importance of nutrition for maintaining health, protecting the feet from injury and the benefits of walking for exercise, improving oxygenation capacity and maintaining function.  Education programs based on empowerment, client participation, and adult learning principles have demonstrated effectiveness (Kennedy, et. al, 2003).

-Teach the importance of the yearly flu vaccine

*

Client identified some lifestyle changes needed to increase tissue perfusion at 11:15 on [Month] 3, 2009.

Interventions were successful, goal achieved on [Month] 3, 2009.

AEB:

CP:  Elevated serum BNP, troponin  intermittent chest pain, PA:  diminished posterior tibialis pulses bilaterally and no hair on the legs,   Low serum hemoglobin, low serum hematocrit.

GI:  reports of intermittent abdominal pain and nausea, elevated lipase.