CM1

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Pt. Initials: CM Age: 81 Allergies: Penicillin PMH: Breast cancer, cirrhosis of liver. Reason for Hospitalization/visit: came in for edema of leg and weakness

Nursing Diagnostics/ Problem: Risk of injury Subj & Obj data (AEB): Malnutrition, altered mobility, past falls, weakness,

Pt Goal: Patient remains free of injuries. Nursing Interventions for goal (numbered): Keep bed low Slippers socks Validate the patient’s feelings and concerns related to environmental risks Coordinate with physical therapist for strengthening exercises and gait training to increase mobility.

Evaluation of Goal: pt did not fall during shift. She had gripper socks on and the bed was in a low position to decrease injury.

Nursing Diagnostics/ Problem: Imbalanced Nutrition: Less Than Body Requirements Subj & Obj data (AEB): Radiation therapy in the past, Surgery, Unwillingness to eat.

Pt Goal: Patient presents understanding of significance of nutrition to healing process and general health. Nursing Interventions for goal (numbered): Ascertain healthy body weight for age and height. Provide a pleasant environment. Provide companionship during mealtime. Consider six small nutrient-dense meals instead of three larger meals daily to lessen the feeling of fullness. Offer liquid energy supplements.

Evaluation of Goal: Pt was encouraged during breakfast to eat and I gave her a snack 2 hours after.

Nursing Diagnostics/ Problem: Impaired Skin Integrity Subj & Obj data (AEB): Immobility,Imbalanced nutritional state,Radiation in the past, has a Braden score of 17.

Pt Goal: Client will experience healing of pressure ulcers and experiences pressure reduction. Nursing Interventions for goal (numbered): Assess the specific risk factors for pressure ulcer Assess the client’s nutritional status, including weight, weight loss, and serum albumin levels, if indicated. Assess the skin on admission and daily for an increasing number of risk factors. Assess for a history of radiation therapy. Use the Braden scale.

Evaluation of Goal: I turned pt every 2 hours and checked skin while I did it.

Nursing Diagnostics/ Problem: Activity Intolerance Subj & Obj data (AEB): ℅ pain, Generalized weakness, Lack of motivation, Prolonged bed rest

Pt Goal: Pt physical activity will return to baseline before returning home. Nursing Interventions for goal (numbered): Have the patient perform the activity more slowly Assist with ADLs while avoiding patient dependency. Encourage physical activity consistent with the patient’s energy levels. Encourage verbalization of feelings regarding limitations. Encourage active ROM exercises.

Evaluation of Goal: Pt took time with activities and showed no weakness. I help pt with morning care and ADL. pt did as much activity as she can before I help her.