Assessment Diagnosis Planning Implementation Rationale Evaluation

Subjective data Activity After 8 hours of - Assess the degree of - Provides information After 8 hours
“He has become Intolerance nursing discomfort through on what activities to of nursing
progressively weaker, related to interventions non-verbal cues. avoid. intervention:
unable to ambulate,
progressive patient will be
unable to carry on a
meaningful conversation, disease state able to: - Assess sleep - Sleep deprivation - Client was
and increasingly secondary to patterns and note could mean emotional able to remain
incontinent of bowel and end-stage - Identify factors changes. distress and free from any
bladder” as verbalized by dementia as that can progression of disease. complications
the patient’s daughter. evidenced by negatively affect but is still in
immobility. performance and - Advise family to - Stress may increase an unable to
Nurse assistant reported the fatigue and client
reduce their create a stress free ambulate
the patient moaned while may develop
turning. effects if possible. environment for the condition.
emotional distress.
- Remain free of client.
Objective data preventable GOAL
Vital signs discomfort and - Instruct family and - Enhances PARTIALLY
Temp- 36⁰C further caregivers in energy performance while MET
Resp. rate- 44 cpm. complications. conservation conserving limited
Pulse rate- 78 bpm energy, preventing
techniques.
Blood pres.- 76/48 fatigue.
mmHg
- Identify safety; with - Protects not only the
(+) Hydration IV at 75 use of assistive patient but also the
cc/hr. devices, temperature caregiver from injury
(+) Dehydration of bath water, and during activities of
(-) Appetite environment. daily living.

Medical History
- Diagnosed with end- - Encourage
- Necessary to meet
stage edema. nutritional intake and energy needs for
use of supplements as activity.
 appropriate.

Physical Assessment - Provide

*General Appearance - Increases
supplemental oxygen
- Lethargic and Unable oxygenation.
to ambulate. as indicated and Evaluates
monitor response. effectiveness of
*Neurologic therapy.
- Decreased level of
consciousness - Assist with comfort
measures such as - May relieve client’s
*Lungs and Chest discomfort and
massage, back rub, or
- Coughing for months provide relaxation.
and crackles sound in the helping with position
lung fields. of comfort.

*Lower extremities - Provide a relaxing

- Signs of edema. environment by - Increases the mood
putting on some of the client and may
*Bowel & Bladder increase client’s
music or opening
- Increased incontinence energy level.
windows.
*Others
- Irregular apical pulse

Assessment Diagnosis Planning Implementation Rationale Evaluation

Subjective data Anticipatory After 8 hours of - Facilitate - Trust is necessary After 8 hours
“…I tried to feed him his grieving related nursing development of a before patient and/or of nursing
oatmeal this morning, but to progressing intervention trusting relationship family can feel free to intervention:
he seemed to choke. He’s loss of patient will be with patient and open personal lines of
been coughing when he physiological able to: family. communication with - Client was
eats for a couple of
well-being as the hospice team. able to remain
months now.” As
verbalized by patient’s evidenced by - Increase activity free
daughter negative level. - Assess sleep - Sleep deprivation discomfort
changes in - Show signs of patterns and note could mean emotional and was able
Case indicated that eating habits, good appetite. changes. distress. to show an
Jake’s symptoms clearly activity levels, - Remain free of increase in
indicate end-of-life and any discomfort. - Assess non-verbal - Non-verbal cues may positive
process. express client’s
communication - Maintain cues of the client feelings.
thoughts and feelings.
Objective data patterns. positive feelings during ADLs. - The family
Vital signs and a good mood. was able to
Temp- 36⁰C -Provide open, - Promotes and verbalize
Resp. rate- 44 cpm. Desired Family nonjudgmental encourages positive understanding
Pulse rate- 78 bpm Outcome: environment. Use feelings and concerns. about the
Blood pres.- 76/48 therapeutic May also increase situation and
mmHg client’s mood.
- Verbalize communication skills come to a
(+) Hydration IV at 75 understanding of of active listening, decision.
cc/hr. the stages of grief affirmation, and so
(+) Dehydration and loss, ventilate on. GOAL MET
(-) Appetite conflicts and
feelings related to - Set limits on - Indicators of
Medical History illness and death. inappropriate ineffective coping and
- Diagnosed with end- need for additional
behavior, redirect
stage edema. interventions.
negative thinking. Be
Preventing destructive
aware of mood actions enables patient
swings, hostility, and to maintain control
Physical Assessment other acting-out and sense of self-
*General Appearance behavior. esteem.
- Lethargic and Unable to
ambulate. - Assist patient and
- Recognizing these
family to identify
*Neurologic resources provides
- Decreased level of strengths in self or opportunity to work
consciousness situation and support through feelings of
systems. grief.
*Lungs and Chest
- Coughing for months - Assist client in
and crackles sound in the accepting whatever - Caregiver’s decisions
lung fields. may not be in line
methods the family
with client’s point of
*Lower extremities has chosen for client view.
- Signs of edema. care.

*Bowel & Bladder - Assist family in

- Increased incontinence choosing a decision - Caregiver’s may
for healthcare by have a hard time in
*Others creating a decision for
exploring options.
- Irregular apical pulse their family.
- Refer to appropriate - Compassion and
counselor as needed. support can help
alleviate distress or
palliate feelings of
grief.