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Nursing Process: Clustering Data

Group your abnormal patient assessment data to identify key problem areas to become nursing diagnoses
Key Problem: Key Problem: Key Problem: Key Problem:

Airway breathing circulation Disability

Abnormal Assessment Data: Abnormal Assessment Data: Abnormal Assessment Data: Abnormal Assessment Data:

tremors

Unsteady

Fatigue

Drooling
 Nursing Process: Nursing Diagnosis
Concept Map and Prioritization
Problem Area:
Problem Area:
Priority No. 2
Priority No. 1
Nursing Diagnosis:
Nursing Diagnosis:
Patient Initials: old man
Impaired physical mobility R/T rigidity
Imbalanced nutrition R/T Inability to
AEB joint stiffness and Decreased
ingest or digest food or absorb nutrients
muscle strength and limited range of
AEB he has difficulty swallowing.
motion.

Age: 60 years

Problem Area: Diagnosis on admission: Problem Area:

Priority No. 3 Parkinson’s disease Priority No. 4
Nursing Diagnosis: Nursing Process: Nursing Care Plan Nursing Diagnosis:

risk for fall R/T unsteady on his feet. Impaired verbal communication R/T
Parkinson's disease AEB the patient
demonstrates Slow, slurred, and
monotone speech pattern.

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GTNI: NU 102 Adult of Nursing Practice: Clinical Package
 Primary Nursing Diagnosis (Priority 1): Impaired physical mobility R/T rigidity AEB joint stiffness and Decreased
muscle strength and limited range of motion.
Primary Nursing Diagnosis (Priority 2): Impaired verbal communication R/T Parkinson's disease AEB the patient demonstrate
Expected
Slow, slurred,Outcomes/Goals:
and monotone speech pattern. Evaluation of outcome for this shift:
Verbalize need for self-directed activity.
Expected Outcomes/Goals: Evaluation of outcome for this shift:
The patient will Verbalize the need for a behavioral
Outcome for this shift: Demonstrate congruent verbal and change to
improvecommunication.
nonverbal physical activity.
Overall
Overall Goal:
Goal:

Interventions
Interventions Rationale
Rationale Evaluation
Evaluation of Intervention
of Intervention
(Plan
(Plan of nursing
of nursing management
management for for
thisthis (Why(Why
thethe intervention
intervention should
should be undertaken
be undertaken – – (How (How
thethe patient
patient responded
responded to
to the
diagnosis)
diagnosis) information
information from from acceptable
acceptable resource)
resource) the intervention)
intervention)
Validate meaning of nonverbal because they may be wrong.
Ask the clientdo
communication; hownothe or she perceives
make
the situation to gather his personal vision
assumptions. Clients and caregivers may have different
of the problem and how they envisage priorities on what is important
their self-involvement. Specify the goals.
Provide environmental stimuli as needed. to reduce stimuli to lessen anxiety that may
worsen problem.
Support affected body parts/joints using to maintain position of function and reduce risk of
Usepillows/rolls,
confrontationfoot supports/shoes,
skills, when air pressure
to clarify ulcers.
discrepancies between verbal and
mattress, waterbed, and so forth.
appropriate, within an established nurse- nonverbal cues.
client relationship
Administer medications prior to activity as to permit maximal effort/involvement in activity.
needed ability
Determine for pain
to relief
read/write. To Evaluate musculoskeletal states, including
Schedule activities with adequate rest to reduce
manual fatigue
dexterity.
periods during the day
Consult with physical/occupational to develop individual exercise/mobility program
therapist as indicated. and identify appropriate adjunctive devices.

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GTNI: NU 102 Adult of Nursing Practice: Clinical Package