Fluid and Electrolyte
Sensory/Comfort
Alert and oriented X 2 person and place,
somnolence, Pupils PERRLA, face was
symmetrical, speech is clear but slow to
respond, bilateral upper and lower extremities
were not responsive to sensation, grasp on
right and left hands are weak, lower
extremities showed signs of impaired muscle
strength, lower extremities unable to apply
force against resisting force, impaired range
of motion bilateral upper and lower
extremities, Patient pain at 0800 on 03/20/18
was 6 out of 10 and a 6 out of 10 at 1100, 8
out of 10 at 1400 Patients tolerable pain level
is 5. Hospital Medication: Norco 5-325mg
one tablet by mouth every 4 hours as needed
for pain (Acts directly on cough center in
medulla to suppress cough; binds to opiate
receptors in CNS to reduce pain)
Inference: Patient pain at 0800 on
03/20/18 was 6 out of 10 and a 6 out of 10 at
1100, 8 out of 10 at 1400 Patients tolerable
pain level is 5 resulting from inflammation of
the kidneys (pyelonephritis)
Mobility
Unable to ambulate without assistance,
weight baring as tolerated, uses bedside rails,
gait imbalance due to lower extremity
weakness and loss of sensation (Buillain
Barre Syndrome), bed in lowest position,
stands with gait belt, Morse 55 (high risk),
history of falls, fall precautions,
Inference: Unable to ambulate without
assistance, gait imbalance, lower extremity
weakness and loss of sensation resulting from
Guillen barre Syndrome
Endocrine
glucose on 03/20/18 at 0800 183 (H) (70-
140), glucose on 03/20/18 at 1300 was 243
(H) Hospital medications: Insulin Regular
Human sliding scale Inj (Decreases blood
glucose; by transport of glucose into cells and
the conversion of glucose to glycogen,
indirectly increases blood pyruvate and
potassium; insulin may be human), Glucagon
Inj 1mg (increases in blood glucose,
relaxation of smooth muscle of the GI tract,
and a positive inotropic and chronotropic
effect on the heart; increases in blood glucose
are secondary to stimulation of
glycogenolysis),
Inference: glucose on 03/20/18 at 0800
183 (H) (glucose on 03/20/18 at 1300 was
243 (H), not always consistent with a healthy
diet, leading to diabetes
Skin warm and dry to touch, incontinent,
pyelonephritis, nausea, IV site left antecubital
(size 18), no inflammation or redness noted,
NA on 3/18/18 at 0600 134 (L) (135-145),
Potassium on 03/18/18 at 0600 was 2.8 (L)
(3.5-5.0) Input on 03/19/18 of fluid was 1200
ml and Output on 03/19/18 700ml (yellow
clear) Hospital medication: Sodium chloride
0.9% IV premix, Dextrose 50% inj sol via IV,
D5-NaCL 0.45% IV premix ,ceftriaxone one
1 vial Gram intravenous (uncomplicated
gonorrhea),
Inference: nausea, incontinence, IV
insertions, potassium 2.8(L) resulting from
infection of the kidneys (pyelonephritis)
70-year old Caucasian male, admitted on 03/15/18 due to
pyelonephritis. CC Flanking pain PMH (Hospital) Hypothyroidism,
essential hypertension, claudication due to peripheral vascular disease,
prediabetes, hyperlipidemia, bilateral carotid artery stenosis, umbilical
hernia, pyelonephritis, Guillain Barre Syndrome, Non-Hospital
hyperglycemia, weakness in bilateral lower extremities, Vitamin D
deficiency, Left Inguinal hernia, Braden scale 10 (high risk), Home
medications: Levothyroxine 88 mcg one tablet by mouth daily 30
minutes before breakfast (Increases the metabolic rate of body tissues),
amlodipine 5mg one tablet by mouth daily(inhibits calcium ion influx
across cell membrane during cardiac depolarization), atorvastatin 40
mg one tablet by mouth at bedtime(inhibits HMG-CoA reductase
enzyme, which reduces cholesterol synthesis) , Cholecalciferol 1000
units one tablet by mouth daily(Promotes the intestinal
absorption of dietary calcium (requires activation in the
liver and kidneys to create the active form of vitamin
D3, promotes the intestinal absorption of dietary
calcium), Cilostazol 100mg one tablet by mouth two times a day
(multifactorial effects), NKA, married, retired, Full code, Insurance
private, no spiritual or religious considerations, EDD pending awaiting
doctors’ orders,
Nutrition
Bowel sounds present and normal in all 4
quadrants, last bowel movement 03/20/18 at
1200, no evidence of dysphagia, 5’11 inches,
214.5 lbs., BMI of 30 % (obese) nauseated, ,
cardiac diet, diabetic diet, client has eaten 90-
100% of breakfast lunch and dinner, Hospital
medication: Ondansetron Injection 4mg
(blocks specific receptor sites 5-HT3, which
are associated with nausea and vomiting in
the chemoreceptor trigger zone, centrally and
at specific sites peripherally), Mylanta oral
susp 30ml by mouth daily (Flatulence)
Inference: BMI 30%, diabetes diet, as a
result of diabetes
Cardiovascular
Heart sounds normal S1 and S2, no bruit
heard over carotid artery, denies any chest
pain, poor cap refill >3 seconds, O2
saturation 94% with no activity (L) (95-
100%) at 0754 on 03/20/18 and 96% with no
activity at 1100, pulse rate on 03/20/18 at
0754 94(N) (60-100 bpm) and 86 (N) on at
1100, blood pressure on 03/20/18 153/83 (H)
(Systolic 90-139) at 0754 and 143/83 (H) at
1100, RBC AUTO 4.43 (L) (4.7-6.1) on
03/17/18 at 0600 and 4.09 (L) on 03/18/18 at
0600 and on 03/20/18 was 4.45 (L) at 0600 ,
WBC 12.8 (H) (4.0-11.0) on 03/17/18 at 0600
and13.0 (H) on 03/18/18 at 0600, and 12.2
(H) on 03/20/18 at 600, HGB 14.5 (N) (14-
18) on 03/17/18 at 0600, 13.4 (L) on 03/18/18
at 0600, and 14.5 (N) on 03/20/18 0600,
Lymph’s Auto 0.80 (L) (1.00-3.60) on
03/17/18 at 0600, 0.65 (L) on 03/18/18 at
0600, and 0.83 (L) on 03/20/18 at 0600,
MONOS auto on 03/17/18 at 0600 was 1.64
(H), on 03/18/18 at 0600 was 1.20 (H), and
on 03/20/18 was 1.27 (H), skin proper to
ethnicity, peripheral pulse present bilaterally
in lower extremities (+3), Hospital
medication: amlodipine 5mg one tablet by
mouth daily (inhibits calcium ion influx
across cell membrane during cardiac
depolarization), aspirin chew tablet 81mg by
mouth daily (blocks pain impulses by
blocking COX-1 in CNS, reduces
inflammation by inhibitions of prostaglandin
synthesis; antipyretic action results from
vasodilation of peripheral vessels decreases
platelet aggregation), atorvastatin 40 mg one
tablet by mouth at bedtime (inhibits HMG-
CoA reductase enzyme, which reduces
cholesterol synthesis), Heparin Porcrine
Injection 5,000 units daily subcutaneous
(prevents conversion of fibrinogen to fibrin
and prothrombin to thrombin by enhancing
inhibitory effects of antithrombin III)
Inference: WBC 12.8 (H) Lymph’s Auto
0.80 (L) MONOS auto 1.64 (H), resulting
from infection of the kidneys (pyelonephritis)
Nursing Diagnosis (According To Nanda And By Priorities): Need According To Maslow (I.E., Physiological/Oxygen)
1. Ineffective protection related to decrease in ability to guard self from internal or external threats such as 1. Physiological
illness or injury as evidence by WBC 12.8 (H), lymph 0.80 (L), Monos 1.64 (H), administration of ceftriaxone
2. Ineffective health management related to pattern of regulating and integrating into daily living a therapeutic 2. Physiological
regimen for the treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals as
evidence by blood glucose level 183(H) at 0800 on 03/20/18, blood glucose level 243 at 1300 on 03/20/18,
administration of insulin, not always being compliant with a diabetic diet
3. Acute pain related to an unpleasant sensory and emotional experience associated with actual or potential 3.Phsyiological
tissue damage, or described in terms of such damage as evidence by Patient pain at 0800 on 03/20/18 was 6
out of 10, a 6 out of 10 at 1100, 8 out of 10 at 1400, patient complaining of flanking pain, medical diagnosis of
pyelonephritis

Plan (Outcome Criteria) Interventions (With Rationale) Evaluation

Client will understand how to reduce the risk of spreading
infection by 1700 on 03/20/18
1) Assess temperature, pulse, and blood pressure Patient was able to explain proper measures to reduce
Rational: Changes in vitals can show course of infection infection at home by 1700 on 03/20/18
2) Assess all invasive sights and use chlorhexidine gluconate for cleansing
Rational: Use of chlorhexidine gluconate for vascular catheter site care reduces
catheter related bloodstream infections and catheter colonization
3) Teach precautions to use to decrease the chance of infection, such as proper hand
wash and proper hygiene
Rational: Decreases risk for infection at home with proper teaching
4) Monitor permeability and flow rate at regular intervals
Rational: Checking flow rate consistently will reduce medication administration
error
5) Encourage clients to report any discomfort such as pain, burning, swelling, or
bleeding
Rational: The patient’s subjective data is the best form of gathering quick
information

Patients will understand the importance of following a diabetic
diet by 1700 on 03/20/18
1) Collaborate with the client for purposes of meeting health related goals Patient was able to state the importance of following
Rational: The concept of knowing the patient was studied through an integrative diabetic diet at 1700 on 03/20/18
review and found to be a significant factor for clients but the barriers to knowing
the patient are time, expedited client discharges, and consistency of nursing
assignments
2) Collaborate with family members in knowledge development, planning for self-
management, and shared decision making
Diabetic clients view family participation as support and motivation to care for
themselves as supported by three reported themes in a qualitative study: families
needed to be recognized, at times clients blamed family for nonadherence, and
family involvement made clients feel cared for
3) Collaborate with dietician for a proper diabetic diet that meets the patients’ needs
Rational: Dietician can find foods that the client can enjoy yet is still compliant to
a diabetic diet
4) Monitor self-management of the medical regimen
Rational: Patient centered care was analyzed by an extensive multidisciplinary

Client pain level will be within or below tolerable range by
1700 on 03/20/18
literature review and three themes were identified as being fundamental: Client
participation and involvement, the relationship between the client and the health
care professional, and the context in which care is delivered
5) Teach safety in taking medication
Rational: Explored nurse’s perspective on preventing medication administration
errors revealed three themes: nurse’s roles and responsibilities in medication
safety, nurse’s ability to work safely, and nurse’s acceptance of safety practices
placing nurses in a positon to ensure safe medication management
1) Administer a non-opioid analgesic for mild to moderate pain an add an opioid Patient rated pain a 3 out of 10 at 1700 on 03/20/18 which i
analgesic if indicated for moderate to severe acute pain within tolerable range
Rational: Non-opioids, such as acetaminophen and nonsteroidal anti-
inflammatory drugs, are first line analgesics for the treatment of mild and some
moderate acute pain, while opioids are included for the treatment of moderate to
severe acute pain
2) Administer stool softener and stimulant to prevent/treat opioid related
constipation and ask about other opioid related side effects including nausea,
pruritus, lack of appetite, and changes in rest and sleep
Rational: In a study of postoperative orthopedic clients, more than half of the
clients experienced one or more opioid related side effects
3) Assess the clients pain flow sheet and medication administration record to
evaluate effectiveness of pain relief, previous 24-hour opioid requirements, and
occurrence of side effects
Rational: systematic tracking of pain is an important factor in improving pain
management and making adjustments to the pain management regiment
4) Teach the client use of nonpharmacological methods to supplement
pharmacological analgesic approaches to help control pain, such as distraction,
imagery, music therapy, simple massage, relaxation and application of heat and
cold
Rational: although more evidence is needed to conclude effectiveness,
nonpharmacological methods can be used to complement pharmacological
treatment of pain
5) Teach the client to use the self-report pain tool to rate the intensity of past or
current pain. Ask the client to set a comfort function goal by selecting a pain level
on the self-report tool that will allow performance of desired or necessary
activities of recovery with relative ease. If the pain level is consistently above the
comfort function goal, the client should take action that decreases pain or notify a
member of the health care team so that effective pain management interventions
may be implemented promptly
Rational: The use of comfort function goals provides the basis for the direction
and medication of the treatment plan