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ASSESSMENT
FINDINGS
Respiratory System
Cardiovascular
System
History
Nervous System
Food intake
History
Height
Weight
Client is on a diabetic/Heart
Healthy Diet and yesterday
was NPO.
Client has high cholesterol
Client is 175 cm
91kg
Clients BMI is
29.71(preobese)
Will need to assess client for
regular bowel sounds and for
pain.
Clients C.B.C.s, Bun and
Creatine lab val;ues are to be
monitored.
Coma Scale
Evidence of pain acute or chronic
Gastrointestinal
System
Bowel sounds
Pain
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SYSTEM
Urinary System
ASSESSMENT
Urine amount, colour, transparency,
odour
Musculoskeletal
System
Integumentary
System
Evidence of injury/trauma
membranes
Body temperature
Endocrine System
FINDINGS
Endocrine sytem
Pathological History
tissue, integument
Functional change in:
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SYSTEM
Environmental
Factors that Affect
Function of Systems
ASSESSMENT
Support systems
Lifestyle factors
Medical diagnoses
Medications
Determinants of health
FINDINGS
The patient lives with brother
and son, who have been
working with the social
worker on decisions regarding
his care.
Clientss last job ended in
February and he currently
does not have health benefits.
He has Non-Insulin
Dependent Diabetes, has
previously had a heart attack
and has high cholesterol.
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Planning
Interventions
Evaluation
Actual Problem:
Impaired Tissue
Integrity of the
Scrotum and the Back
related to the patients
poor diabetic
management as
evidenced by his falls.
1. Achievement of Expected
Outcomes: The goal was met as
the patients wounds on both his
scrotum and back did now
worsen as evidenced by the
unchanging measurements.
R: He can do so in
collaboration with the ideas
of the Dr., nurses,
Pharmacist and Dietician.
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Potential Problem:
Risk for Falls related to
the patients unstable
blood sugars as
evidenced by his fall on
May 17th, 2014.
Goal: To prevent client from 1. The student nurse will assess the
experiencing more falls.
client for signs of confusion.
S: The patient will wear
well fitted shoes when
walking, wear pajamas and
robes that do not drape on
the ground and will avoid
wet and uneven surfaces.
MA: The client will display
these behaviours everyday
R: during the practical
student nurses shift from
7:00-2:00.
T: This goal will be
maintained from June 3rdJune 20th, 2014.
Rationale
1. A confused state of mind is often
linked to dizziness, loss of ones sense
of position and ultimately loss of
balance (Day, Paul, Williams, Smeltzer,
and Bare, 2010, p. 234).
2. Patients who have to wait an
extended period of time may do unsafe
activities on their own if they have to
wait too long (Gulanick & Myers, 2014,
p.65).
3. According to Potter and Perry, falls in
older adults are often caused by getting
out of bed too quickly and without
assistance (2010, p. 396).
1. Achievement of Expected
Outcomes: The Goal was
achieved primarily because the
patient strived to wear the right
attire while in the hospital and
was more careful noting what
surface he was walking on.
2. Patient Responses and
Findings: This goal was also
successful because the patient
was motivated to learn.
3. Further Nursing Actions: Are
not needed because the patient
goal was met and patient vows
to be more careful and take all of
his medications in the future
(social assistance for this
pending).
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Educational:
Knowledge deficit:
Ineffective Health
maintenance as
evidenced by patients
smoking status.
Rationale
1. Quitting smoking cuts the risk of
Coronary Heart disease by 50% and
following 2 weeks-3 months of quitting
smoking, ones circulation is
improved(Gulanick and Myers, p. 227)
2. Smoking cessation is twice as
affective when nicotine replacement
methods are used as opposed to a
placebo (Gullanick and Meyers, p.227).
3. Smoking according to Gullanick and
Meyers is often used to combat stress,
1. Achievement of Expected
Outcomes: The goal was
achieved as the patient willingly
participated in all discussions.
2. Patient Responses and
findings: The interventions were
especially helpful to the client as
teh client did not realize how
much more successful people
were, when they incorporated
nicotine replacement therapy
into quitting smoking.
3. Further Nursing Actions: The
client now understands why it is
important to quit and
consequently the next nursing
action would be encouraging the
client to quit.
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Summary
A nursing diagnosis according to Durand & Prince is the nurses perspective on the
appropriate focus for the client (Potter & Perry, 2010, p. 64), and is the first step in the nursing
process. This integral part of nursing care helps the nurse determine what problems are present
and furthermore what nursing interventions will work to solve these problems (providing
decisions are evidenced based). In this case, evidence based interventions and outcomes helped
me to decide that the patient needed help with his wound care (an actual problem), and guidance
to prevent him from falling again (a potential nursing diagnosis). The nursing process
furthermore prompted me to form an educational goal, and through this structured way of
thinking I knew I needed to teach my patient more concerning the ill effects of smoking and to
evaluate whether my teachings were effective or not .
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References:
Day, A.R., Paul, P., Williams, B. Smeltzer, S.C., Bare, B. (2010). Brunner & Suddarth's textbook
of Canadian medical-surgical nursing. Philadelphia, PA: Lippincott Williams & Wilkins.
Gulanick, M., Myers, J.L., (2014). Nursing Care Plans: Diagnoses, Interventions and
Outcomes(8th ed.).Philadelphia, PA: Elselvier
Potter, P.A., & Perry, A.G. (2010). Canadian fundamentals of nursing (4th ed.). Ross-Kerr, J.C.,
& Wood, M.J. (Eds., Cdn. ed.). Toronto, ON: Elsevier.