Wellness
Has mild dementia. Is not alert and oriented to time and place.
Meds: Ativan
Labs: N/A
Ordered medical treatments: N/A
Nursing Diagnoses: Acute confusion r/t dementia, polypharmacy
aeb not being oriented to time and place.
Nursing Interventions:
1. Inform a patient of person, place, time, and event as
needed.
Oxygenation
2. Provide new information slowly and in small doses.
Cardiovascular
3. Provide reality orientation as needed.
Meds: clopidogrel (Plavix), digoxin, metoprolol, potassium
chloride,
Labs: WBC 8.4; RBC L3.45; HGB L 11.3, HCT L33.4
Ordered medical treatments: N/A
Nursing Diagnoses: Ineffective peripheral tissue Perfusion r/t
deficient knowledge of disease process (hypertension) aeb blood
pressure changes in extremities, diminished pulses.
Nursing Interventions:
1. Check the brachial, radial, dorsalis pedis, posterior tibial,
and popliteal pulses bilaterally. If unable to find them,
use a Doppler stethoscope and notify the physician
immediately if new onset of pulses is not present.
2. Note the presence of edema in the extremities and rate
severity on a four-point scale.
3. Note skin color and feel the temperature of the skin.
Respiratory
Experience dyspnea, SOB upon exertion. Admitted with
pneumonia.
Meds: furosemide, vancomycin, Zosyn
Labs: Chest X-ray: positive for pleural effusion and atelectasis.
Blood test negative for septicemia.
Ordered medical treatments: O2 @ 2L/Min per NC
Nursing Diagnoses: Impaired Gas Exchange r/t ventilation-
perfusion imbalance secondary to atelectasis, lung mass aeb
abnormal ABGs, dypsnea.
Nursing Interventions:
1. Monitor oxygen saturation continuously using pulse
oximetry. Note blood gas results as available.
2. Auscultate breath sounds every 1 to 2 hours. The
presence of crackles and wheezes may alert the nurse to
airway obstruction.
3. Monitor respiratory rate, depth, and ease of respiration.
Watch for use of accessory muscles and nasal flaring.
Self-Expression
Seems to be withdrawal sociably. Does not like
too much interaction. Wants to be left alone to
rest most of the time.
Meds: Lorazepam, mirtazapine (Remeron)
Labs:
Ordered medical treatments:
Nursing Diagnoses: Social isolation r/t altered
state of wellness, depression aeb seeks to be
alone, withdrawn.
Nursing Interventions:
1. Establish a therapeutic relationship by
being emotionally present and
authentic.
2. Observe barriers to social interaction.
3. Provide positive reinforcement when
client the client seeks out others.
Student Name: Thuyan Nguyen
Pt. Room: 564 Age: 94 Female
Patient Initials: SJ
Primary Medical Dx: Failure to Thrive
Secondary Medical Dx’s: Pneumonia,
Atelectasis, Malaise, Post Herpetic
Neuropathy
How do these impact primary dx’s?
Allergies: Drugs: Foods: No Chemicals: No
Type of response: Unknown
Sleep/Pain
Meds: Acetaminophen, Acetaminophen-
hydrocodone (Norco), hydrocodone
Labs: N/A
Ordered medical treatments: N/A
Nursing Diagnoses: Acute pain r/t injury agents
(biological) secondary to post herpetic neuralgia
aeb patient report of pain (5 on 0-10).
Nursing Interventions:
1. Assess pain level in a client using a valid
and reliable self-report pain tool, such
as the 0-10 numerical pain rating scale.
2. Assess the client for pain presence
routinely at frequent intervals, often at
the same time as vital signs are taken,
and during activity and rest.
3. Obtain a prescription to administer an
opoid analgesic if indicated, especially
for moderate to severe pain.
Skin and Tissue
Experiencing post herpetic neuralgia due to
Shingles. Has stage 2 pressure ulcer in coccyx
area.
Meds: Lidocain (topical)
Labs: N/A
Ordered medical treatments: N/A
Nursing Diagnoses: Impaired Tissue Integrity r/t
impaired physical mobility; mechanical factors
(pressure) aeb stage two pressure ulcer in
coccyx.
Nursing Interventions:
1. Do not position the client on the site of
impaired tissue integrity.
2. Avoid massaging around the site of
impaired tissue integrity and over bony
prominences.
3. Monitor the site of impaired tissue
integrity at least once daily for color
changes, redness, swelling, warmth,
pain, or other signs of infection.
Elimination (Bowel & Bladder)
Last bowel and urinary emptying 11/30/10.
Experiencing both bowel and urinary
incontinence.
Meds: N/A
Labs: N/A
Ordered medical treatments: N/A
Nursing Diagnoses: Functional urinary
Incontinence r/t neuromuscular limitations
impairing mobility aeb inability to ambulate self
to BSC.
Nursing Interventions:
1. Assess the client in an acute care or
rehabilitation facility for risk factors for
functional incontinence.
2. Assess the client for mobility, including
the ability to rise from chair and bed,
transfer to the toilet, and ambulate,
and the need for physical assistive
devices such as a cane, walker, or
wheelchair.
3. Monitor the elderly client in a long-
term care facility, acute care facility, or

Neurosensory
Has post herpetic neurgalgia. Able to feel sense of touch bilaterally on
both upper and lower extremities. Has a good grip.
Meds: Pregabalin (Lyrica)
Labs: N/A
Ordered medical treatments: N/A
Nursing Diagnoses: Risk for injury r/t sensory dysfunction.
Nursing Interventions:
1. Remove all possible hazards in environment such as razors,
medications, and matches.
2. Help client sit in a stable chair with armrests. Avoid use of
wheelchairs and geri-chairs except for transportation as needed.
3. Refer to PT for strengthening exercises and gait training to
increase mobility.
Mobility
Needs moderate assist when ambulating. Ambulate with use of walker.
Meds: N/A
Labs: N/A
Ordered medical treatments: N/A
Nursing Diagnoses: Impaired physical Mobility r/t activity intolerance, reluctance to
initiate movement, muscle weakness aeb trembling, dyspnea, “I don’t want to go
anywhere, don’t move me, I’m tired”
Nursing Interventions:
1. Assess the client for cause of impaired mobility. Determine whether the
cause is physical, psychological, or motivational.
2. Before activity, observe for and, if possible, treat pain with massage, heat
pack to affected area, or medication. Ensure that the client is not
oversedated.
3. Consult with PT for further evaluation, strength training, gait training, and
development of a mobility plan.

Nutrition Fluid Balance

Oral mucosa is pink, dry. Sluggish skin turgor. Does not drink sufficient fluids.
Poor appetite. Eats about 25% of meals at all meals.
Meds: N/A
Meds:
Labs: Na+ 137; K+ 4.3; Chloride 104
Labs: BUN 11; Creatinine 0.7, BUN/Creat 16, glucose H 130, calcium L8.0
Ordered medical treatments: N/A
Ordered medical treatments:
Nursing Diagnoses: Deficient Fluid volume r/t active fluid volume loss aeb decreased
Nursing Diagnoses: Imbalanced Nutrition: less than body requirement r/t
skin turgor; dry skin.
psychological factors aeb by lack of interest in food.
Nursing Interventions:
Nursing Interventions:
1. Watch for early signs of hypovolemia, including thirst, restlessness,
1. Weight client daily in acute care, weekly in extended care at the
headaches, and inability to concentrate. Thirst is often the first sign of
same time, with same amount of clothing.
dehydration.
2. Compare usual food intake with the Food Guide Pyramid, noting
2. Observe for dry tongue and mucous membranes, and longitudinal
slighted or omitted food groups.
tongue furrows.
3. If the client lacks endurance, schedule rest periods before meals,
and open packages and cut up food for client (pureed diet if
3. Weigh client daily and watch for sudden decreases, especially in the
presence of decreasing urine output or active fluid loss.
ordered).
Other Instructor comments: