NUR1211CSYLLABUS/COURSEOUTLNEOCTOBER2011/PYC

FALL 2011
SYW

CLIENT MEDICAL HISTORY
FORM #1
Student Name: Tammy Nguyen
Client nitials: J.C
Room Number: 433-2
Date of Admission: 11/18/11
Dates of care: 11/20/11-11/21/11

M/F Male
Age 76
Admitted with a chief complaint of: nausea, constipation and pain in his right lower quadrant.
Medical Diagnosis: Large Cell Lymphoma

Presenting Illness (symptoms/surgery): The client is a 76-year-old male with a complaint of pain and
constipation. He reports pain in his right lower quadrant. He describes the pain as constant and sharp,
worse with movement and deep breathing.

Past Health History: Prostate cancer, myelodysplastic sydrome, anemia, renal insufficiency.

Social History: The client lives with his wife and has a daughter name Anna who lives locally. He is a
nonsmoker and nonalcoholic.

Allergies: No known drug allergies.
Vital Signs
T: 97.6 P: 83 B/P: 130/87 R: 18 O2 SAT: 98% RA Pain Scale: 6/10

Diagnostic tests ordered while in the acute care setting: CBC, Bmp, Xray

Interdisciplinary collaboration (identify each discipline/department involved):
O Nurses/Techs
O Pharmacy
O Emergency Doctors/Nurses
O Nutrition
O Laboratory
O Housekeeping
O Physicians
O Radiology
O Transporters
O Cardiology
O Respiratory

CURRENT ORDER STATUS
Advanced Directive on the chart: Living Will
ode Status: DNR
Activity Level: Up ad lib and bedrest
Diet (If NPO, why?): Diabetic
Strict I&O (If yes, why?): Yes due to his diarrhea and constipation.
Fluid Restrictions (If yes, why?): The client is not on fluid restrictions.
Telemetry (must check the rhythm twice/shift):
1. Sinus
2. Sinus
Isolation (If yes, why?): No
Oxygen Therapy: RA
Incentive Spirometry (Qhours): The client is not using an incentive spirometer.
NUR1211CSYLLABUS/COURSEOUTLNEOCTOBER2011/PYC
FALL 2011
SYW

Dressings and Wound are: The client has a stage 1 ulcer on his coccyx.
Drains/atheter/Tubes: The client has a PCC line in his right arm.
Discharge Plan: The client will have less or no diarrheal episodes and no constipation as well as resume
usual bowel pattern. He will maintain adequate nutritional and fluid intake. The client will also keep his
skin clean and free from irritation to reduce and prevent ulcerations.
Other important data about the client: The client's pain went from a 6 last week to a 0 this week. He is
doing great and is so pleasant. He is in a cheerier mood. This could also be due to the great amount of
support he gets from his "brothers and sisters at his church.





























RASMUSSEN COLLEGE
School of Nursing
FORM #3
PATHOPHYSIOLOGY

Student Name: Tammy Nguyen
Client nitials: J.C Client Room Number: 433-2

ExpIanation of aII current and pertinent past MedicaI Diagnosis

Diagnosis Large Cell Lymphoma

Pathophysiology Lymphoma is the most common blood cancer. The two main forms of lymphoma are
Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL). Lymphoma occurs when lymphocytes, a
type of white blood cell, grow abnormally. The body has two main types of lymphocytes that can develop
into lymphomas: B-lymphocytes (B-cells) and T-lymphocytes (T-cells). Cancerous lymphocytes can travel
to many parts of the body, including the lymph nodes, spleen, bone marrow, blood or other organs, and
can accumulate to form tumors. (Berman, Snyder, Kozier, Erb, 2008).

NUR1211CSYLLABUS/COURSEOUTLNEOCTOBER2011/PYC
FALL 2011
SYW

Textbook Signs and Symptoms The first sign of large cell lymphoma is often a quickly growing, non-
painful mass in a lymph node in the neck, groin, or abdomen. Patients may also experience fever, weight
loss, drenching night sweats, or other symptoms.
lient's Signs and Symptoms The client experience tremendous pain in his abdomen, which caused his
excessive constipation.

Recommended Treatments The treatment depends upon whether the disease is advanced or localized.
Advanced disease combination chemotherapy plus immunotherapy.
LocaIized disease Patients with localized disease may be treated with fewer cycles (usually three
cycles) of R-CHOP chemotherapy in combination with radiation therapy to the involved area.
urrent Treatments The client is currently receiving treatment.

Teaching Age, gender, and ethnicity affect a person's likelihood of developing DLBCL. Although DLBCL
has been found in people of all age groups, it is found most commonly in people who are middle-aged or
elderly. The average age at the time of diagnosis is 64 years. Men are slightly more likely to develop
DLBCL than women. n the United States, white people are more likely to develop this type of lymphoma
than are Asians or Blacks.
Prevention There are no known preventions however, with this syndrome, it makes clients more
susceptible to infections. To prevent infection or worsening of an infection:
O Wash hands
O Avoid people who are ill
O Be careful with food. Cook food thoroughly.






























NUR1211CSYLLABUS/COURSEOUTLNEOCTOBER2011/PYC
FALL 2011
SYW

RASMUSSEN COLLEGE
School of Nursing
FORM #4


DIAGNOSTIC RESULTS FOR IMAGING AND CARDIAC STUDIES

CIient InitiaIs: J.C


Diagnostic
Test
Date of
Test
Test ResuIt Body
System
Tested
MD Treatment
PIan for Test
ResuIts
Nursing
ImpIications for
MD Treatment
Date of
Re-
Check
Portable
Chest X-
Ray
11/18/11 Chest
stable.
PCC in
place.

Chest - - -



































NUR1211CSYLLABUS/COURSEOUTLNEOCTOBER2011/PYC
FALL 2011
SYW

RASMUSSEN COLLEGE
School of Nursing
FORM #5
DIAGNOSTIC TESTING
DIRECTIONS
O Describe rationale for selection of laboratory results for your patient.
A CBC was done to check for infection and a BMP was done to monitor the following labs:
4 Sodium for edema and hypertension
4 Potassium to check for cardiac arrhythmia
4 Chloride for elevated levels related to acidosis as well as too much water crossing the
cell membrane.
4 CO2 level to check the respiratory exchange of carbon dioxide in the lungs
4 Calcium for bone metabolism, protein absorption, fat transfer muscular contraction,
transmission of nerve impulses, blood clotting and cardiac function
O dentify measuring units and the normal range of each blood specimen.
O ndicate each client value as High with an "H; Low with an "L' or NormaI with an "N.
HEMATOLOGY
TEST RB
C
HGB HC
T
MC
V
MC
H
MCH
C
MP
V
RD
W
PLT WB
C
neutrop
hiI
basop
hiI
eosi
n
Unit of
Measu
re
m/u
l
g/dL % Fl pg g/dl Fl % k/cm
m
k/ul % % %
Norma
I
Range
4.2-
5.4
0
12.0-
16.0
37-
47
80-
99
27-
34
32-
36
8.9-
13
11.
5-
14.
5
145-
355
4.0-
11.
0
40-70 <2 <6

FemaI
e
12-
6.1
35-
47


MaIe
14.17
.4
42-
51


Date/Time of Test: 11/18/11 1105
TEST RB
C
HG
B
HC
T
MC
V
MC
H
MCH
C
MP
V
RD
W
PL
T
WB
C
neutrop
hiI
basop
hiI
eosi
n

ResuIt
s
2.7 8.3 23.
9
88.
6
30.6 34.6 9.4 18.3 11 3.8 74 1 0
High
Low
Norm
aI
L L L N N N N H LC N N N N

Date/Time of Test: 11/19/11 0520
TEST RB
C
HG
B
HC
T
MC
V
MC
H
MCH
C
MP
V
RD
W
PL
T
WB
C
neutrop
hiI
basop
hiI
eosi
n

ResuIt
s
3.1
3
9.8 27.
8
88.
9
31.4 35.3 9.6 17.3 11 3 65 0 0
High L L L N N N N H LC L N N N
NUR1211CSYLLABUS/COURSEOUTLNEOCTOBER2011/PYC
FALL 2011
SYW

Low
Norm
aI

Date/Time of Test: 1120/11 0610
TEST RB
C
HG
B
HC
T
MC
V
MC
H
MCH
C
MP
V
RD
W
PL
T
WB
C
neutrop
hiI
basop
hiI
eosi
n

ResuIt
s
2.4
9
7.7 22 88.
3
30.7 34.8 9 19 9 2.7 51 1 0
High
Low
Norm
aI
L L L N N N N H LC L N N N
Interpretation of ResuIts: The client's low RBC, high RDW, and low platelet count levels are due to his
anemia. His low HGB and HCT are also low because of the decrease in RBCs. The client's low white
blood cell count is due to malnutrition (Corbett, 2008, pg. 27-34).


COAGULATION STUDIES
Date/Time of Test:
TEST PT PTT INR ADDITIONAL INFORMATION
Unit of
Measure



NormaI
Range




ResuIts

High
Low
NormaI

Interpretation of ResuIts: NA



CHEMISTRY
TEST Sodiu
m
Potassi
um
ChIorid
e
Carbon
Dioxide
GIucos
e
BUN BUN/CRE
AT
Creatini
ne
CaIciu
m
Unit of
Measur
e
mEq/L mEq/L mEq/L Mm/Hg mg/dL Mg/d
L
Ratio Mg/dL Mg/dL
NormaI
Range
136-
145
3.5-5.1 98-107 23-31 70-105 7-18 12-20 0.7-1.3 8.5-
10.1

FemaIe
0.5-1.0

MaIe
0.6-1.3

Date/Time of Test: 11/18/11 1105
TEST Sodiu
m
Potassi
um
ChIorid
e
Carbon
Dioxide
GIucos
e
BUN BUN/CRE
AT
Creatini
ne
CaIciu
m
ResuIts 139

4.2 105 26 186 27 20.3 1.31 9.2
High
Low
N N N N H H N H N
NUR1211CSYLLABUS/COURSEOUTLNEOCTOBER2011/PYC
FALL 2011
SYW

NormaI

Date/Time of Test: 11/19/11 0520
TEST Sodiu
m
Potassi
um
ChIorid
e
Carbon
Dioxide
GIucos
e
BUN BUN/CRE
AT
Creatini
ne
CaIciu
m
ResuIts 135

4.7 106 24 127 35 23.7 1.46 9.1
High
Low
NormaI
N N N N H H N H N

Date/Time of Test: 11/20/11 0530
TEST Sodiu
m
Potassi
um
ChIorid
e
Carbon
Dioxide
GIucos
e
BUN BUN/CRE
AT
Creatini
ne
CaIciu
m
ResuIts 136

5 105 26 123 48 29.5 1.63 9.2
High
Low
NormaI
N N N N H H N H N
Interpretation of ResuIts: The client's high glucose levels are due to his hyperglycemia. His high levels
of BUN and creatinine are due to his dehydration caused from the symptoms of the disease process
(diarrhea, constipation, nausea, and vomiting). (Corbett, 2008, pg. 91-97)

BEDSIDE BLOOD GLUCOSE MONITORING
DATE TIMES BS
RESULT
S
NORMAL
VALUES
INSULIN
GIVEN
TYPE & DOSE
N/A AC (B)
AC (L)
AC (D)
HS

TRENDING SUMMARY
DATE InsuIin
Given
AC (B) InsuIin
Given
AC (L) InsuIin
Given
AC (D) InsuIin
Given
HS






URINALYSIS

Specif
ic
Gravit
y
pH Protein GIucos
e
Ketone BiIirub
in
UrobiIinog
en
RBCs WBCs
Unit of
Measur
e
pH Mg/dL Presenc
e
Presenc
e
Presen
ce
Ehrlich
units/dL
Presenc
e
Presen
ce
NormaI
Range
1.005-
1.030
5.0-
9.0
Less
than or
equal to
15
Negativ
e
Negativ
e
Negativ
e
0.1-1.0 Negative Negativ
e
NUR1211CSYLLABUS/COURSEOUTLNEOCTOBER2011/PYC
FALL 2011
SYW%

Specif
ic
Gravit
y
pH Protein GIucos
e
Ketone BiIirub
in
UrobiIinog
en
RBCs WBCs
ResuIts 1.010 5 - - - - Normal - -
High
Low
NormaI
N N - Negativ
e
Negativ
e
Negativ
e
0.1-1.0 Negative Negativ
e

URINE CULTURE

TEST DATE/TIM
E
POSITIVE/
NEGATIVE
CAUSING
ORGANISM
ADDITIONAL INFORMATION




Interpretation of ResuIts: The client did not have a urine culture.


OTHER DIAGNOSTIC TESTS
DIRECTIONS
O dentify other tests (i.e. blood cultures; sputum cultures; wound cultures)
O dentify additional diagnostic information (i.e. thyroid profiles; liver profiles)

OTHER TESTS
TEST DATE/TIM
E
POSITIVE/
NEGATIVE
CAUSING
ORGANISM
ADDITIONAL INFORMATION



Interpretation of ResuIts: N/A
























NUR1211CSYLLABUS/COURSEOUTLNEOCTOBER2011/PYC
FALL 2011
SYW%

RASMUSSEN COLLEGE
FORM #6
School of Nursing
MEDICATIONS AND IV FLUIDS
CIient InitiaIs: J.C AIIergies: NKDA
IV FLUIDS

IV soIution
+ additives
Rate
mL/hr
PICC/CVL/P
ORT/PIV
Sit
e
gtts
/
min
Time
bag due
to be
change
d
Time
tubing
due to
be
changed
Major/
Common
Side Effects
Nursing
ImpIication
s +
checking IV
site and
pump Q 1-2
Hours

Why on
these
fIuids?
Normal
Saline

50ml/
hr
PCC RU
A
- - - nfiltration of
V site.
Monitor site
for
erythema,
swelling,
itching, and
burning.
Hydration


MEDICATIONS (Including IV medications) (Deglin, J. H. & Vallerand, 2011)
Drug Admin
Time
Dose Route Routine
or PRN
CIass & Action Major/Common
Side Effects
Nursing
ImpIications
Why on
these meds?
Dexamethasone
&
Mteoclopramide

DC Dexa-
32mg,
meto-
80mg in
96ml NS
SubQ PRN Antiemetics/
Corticosteroids
Stimulates
motility of the
upper G tract
and accelerates
gastric emptying.
Drowsiness,
extrapyramidal
reactions,
restlessness,
and anxiety.
Assess patient
for nausea,
vomiting,
abdominal
distention, and
bowel sounds
before and
after
administration.
To decrease
nausea and
vomiting.
Bisocodyl
(Dulcolax)

0900 5mg PO Routine Laxative.
Stimulates
peristalsis
Abdominal
cramps,
nausea,
diarrhea, rectal
burning.
Assess patient
for abdominal
distention and
presence of
bowel sounds.
Asses color,
consistency,
and amount of
stool
produced.
Evacuation of
the colon.
Acetaminophen
(Tylenol)

1100 325mg PO PRN Analgesics and
Antipyretics;
changes the way
the body senses
pain and cools
the body down.

Rash, hives,
difficulty
breathing
Assess
location, type,
and intensity of
pain prior and
after
administration.
Relieves mild
to moderate
pain.
NUR1211CSYLLABUS/COURSEOUTLNEOCTOBER2011/PYC
FALL 2011
SYW

Nitroglycerin
(Nitrostat)
1200 0.4 mg Sublingual

PRN Antianginals.
ncreases
coronary blood
flow and
produces
vasodilation.
Dizziness,
headache,
hypotension,
and
tachycardia.
Monitor blood
pressure and
pulse before
and after
administration.
Assess
location,
duration, and
intensity of
patient's
anginal pain.
Relief and
prevention of
anginal
attacks,
increases
cardiac
output, and
reduction of
blood
pressure.
Oxycodone
(Oxycontin)
0900

20 mg PO PRN Opiod. Binds to
opiate receptors
in the CNS and
alters perception
and response to
painful stimuli.
Confusion,
sedation,
dizziness, and
constipation.
Assess type,
locatin, and
intensity of
pain prior to
and 1 hr
(peak) after
administration.
To decrease
pain.
Promethazine
(Phenergen)
- 6.25 mg

V PRN Anti-emetics and
Antihistamines.
Blocks effects of
histamines.
Confusion,
disorientation,
sedation,
dizziness.
Monitor blood
pressure,
pulse,
respiratory
rate. Assess
level of
sedation.
To diminish
nausea and
vomiting.
Lorazepam
(Ativan)
1200 0.5 mg

PO PRN Antianxiety.
Decreases CNS
by potentiating
GABA, an
inhibitory
neurotransmitter.
Dizziness,
drowsiness,
lethargy.
Assess degree
and
manifestations
of anxiety and
mental status.
Sedation and
decreased
anxiety.
Regular nsulin 0700
and
1600
1 unit

Subcut Sliding
Scale
Antidiabetics.
Lower blood
glucose by
stimulating
glucose uptake
in muscle and
fat.
Hypoglycemia Assess for
symptoms
hypoglycemia
and
hyperglycemia.
Control of
hyperglycemia
in diabetic
patients.
Furosemide
(Lasix)
1200 40 mg

PO Routine Diuretic.
ncreases renal
secretion of
water, sodium,
chloride,
magnesium,
potassium, and
calcium.
Dizziness,
drowsiness,
fatigue,
headache,
insomnia,
seizure
Assess fluid
status and
monitor blood
pressure and
pulse.
Reduce
swelling and
fluid retention.


Ondansetron
(Zofran)
1300 4mg/2ml

V Prn Antiemetics.
Blocks effects of
serotonin.
Headache,
dizziness,
drowsiness,
fatigue,
diarrhea,
constipation.
Assess for
patient for
nausea,
vomiting, and
bowel sounds.
Decreases
nausea and
vomiting.



NUR1211CSYLLABUS/COURSEOUTLNEOCTOBER2011/PYC
FALL 2011
SYW

RASMUSSEN COLLEGE
FORM #7
School of Nursing

TREATMENTS

Oxygen Therapy
Date of Order Description of Therapy

N/A



Wound Care
Date of Order Description of Therapy
N/A




NutritionaI Support
Date of Order Description of Therapy
11/18/11


Cardiac

SuppIements
Date of Order Description of Therapy
N/A



DiaIysis
Date of Order Description of Therapy
N/A




Others
Date of Order Description of Therapy
N/A












NUR1211CSYLLABUS/COURSEOUTLNEOCTOBER2011/PYC
FALL 2011
SYW

NURSING DIAGNOSES-
(Minimum of 2- Physiological, 2- Psychological. 2- Psychosocial, including knowledge deficit)
FORM #8

PRIORITY
#
NURSING
DIAGNOSIS
RELATED/TO
(R/T)
AS EVIDENCED
BY (AEB)
RATIONALE FOR
PRIORITIZATION
1 Constipation

Abdominal muscle
weakness
Reports of
abdominal pain,
urgency, and
cramping.
A timely response to the
urge to defecate is
necessary to maintain
normal physiological
functioning.
2 Excess Fluid Volume



ncreased fluid
retention
Edema in lower
extremities
bilaterally.
Excess fluid volume often
leads to pulmonary
congestion.
3 Activity ntolerance

Weakened
abdominal
muscles
Exertional
dyspnea and
verbal reports of
weakness and
exhaustion.
Client is on bedrest to
decrease metabolic
demands, thus
conserving energy for
healing. Bedrest may also
cause pressure sores if
not turned q2h.
4 mbalanced nutrition less
than body requirements

nability to absorb
nutrients
necessary for
formation of
normal red blood
cells
Decreased
tolerance for
activity, weakness
and loss of muscle
tone.
Client's inability to absorb
nutrients may lead to
malnutrition.
5 Risk for decreased cardiac
output

Fluid overload N/A Fluid overload may lead
to pulmonary edema.
6 Deficient knowledge

Disease process Questions
regarding his
severe symptoms.
Client's inability to full
comprehend the effects
of the disease process
can cause a
misinterpretation of the
information being given to
him.














NUR1211CSYLLABUS/COURSEOUTLNEOCTOBER2011/PYC
FALL 2011
SYW

Nursing Process Report Form
FORM #9

Most pressing (#1)Nursing
Diagnosis (R/T and AEB):
Constipation reIated to
abdominaI muscIe weakness
as evidenced by reports of
abdominaI pain, urgency, and
cramping.
Nursing Interventions Scientific RationaIe
(incIuding references)
Assessment Data
O Subjective Assessment
The client states he gets severe
constipation and the urge to
defecate but couldn't expel. His
pain level is 8/10
O Objective Assessment
Client's vital signs are BP:
130/87, T:97.6, R:18, HR: 83, O2
Sat: 98%, pain: 6/10. Client's
abdomen is distended and tender
when palpated.
Assessment
1. Auscultate bowel sounds.
2. Determine stool color,
consistency, frequency,
and amount.
3. Encourage fluid intake of
2,500 to 3000 mL/day
within cardiac tolerance.
4. Assess perianal skin
condition frequently,
noting changes or
beginning breakdown.

Decrease Stressors and/or
Strengthen Lines of Defense
1. Limit foods with little or
no fiber (e.g., ice cream,
cheese, meat, and
processed foods).
2. Promote adequate fluid
intake, including water,
high-fiber fruit, and
vegetable juices.
3. Encourage daily activity
and exercise within limits
of individual ability.

Teaching CounseIing
1. Provide information and
resources to client and
spouse about relationship
of diet, exercise, fluid,
and appropriate use of
laxatives.
2. Provide social and
emotional support to help
client manage actual or
potential disabilities
associated with long-term
bowel management.
3. Discuss customary
elimination habits (e.g.,
Assessment RationaIes 1-3
1. Bowel sounds are
generally increased in
diarrhea and decreased
in constipation.
2. Assists in identifying
causative or contributing
factors and appropriate
interventions.
3. Assists in improving
stool consistency (for
constipation). Also helps
maintain hydration
status if diarrhea is
present.
4. Prevents skin
excoriation and
breakdown.
(Doenges, Moorhouse, Murr,
2010, pg. 500)

Decrease Stressors and/or
Strengthen Lines of Defense
RationaIes: (Doenges,
Moorhouse, Murr, 2010, pg.
202)
1-2. To promote moist, soft
feces and facilitate passage of
stool.

3. To stimulate contractions of
the intestines.

MeasurabIe and ReaIistic
Outcomes
O Short Term
Client will report less pain or no
pain by the end of my shift
10pm on 11/21/11.

O Long Term
Client will verbalize
understanding of etiology and
appropriate interventions or
solutions for individual situation
before discharge.






NUR1211CSYLLABUS/COURSEOUTLNEOCTOBER2011/PYC
FALL 2011
SYW

Short Term Outcome: **x*** Met ***** Partially Met ***** Not
Describe: Within a one-week period, the client was like a whole new person. He was getting up and down
from his bed to the chair on his using his walker. Compared to a week ago, he could barely move without
experiencing some type of pain. He now rates his pain as a 0/10.

Long Term Outcome: **x*** Met ***** Partially Met *****Not Met
Describe: Now that the client is experiencing no more pain, he is alert enough to verbalize that he
understands that the constipation and other symptoms are all part of the disease process; that it is not out
of the norm to experience such symptoms.
































normal urge time). This
helps to identify and
clarify client's perception
of problem. For example,
constipation has been
defined as not only
infrequent stools, but also
straining with bowel
movements, hard stools,
and feeling of incomplete
evacuation.
NUR1211CSYLLABUS/COURSEOUTLNEOCTOBER2011/PYC
FALL 2011
SYW

Nursing Process Report Form

FORM #9

Nursing Diagnosis (R/T and
AEB): Excess fluid volume
related to increased fluid retention
as evidenced by edema in lower
extremities bilaterally.
Nursing Interventions Scientific RationaIe
(IncIuding references)
Assessment Data
O Subjective Assessment
Client stated, "it hurts to walk
because my feet and legs are so
swollen.

O Objective Assessment
Client's vital signs are: T: 97.6, P:
83, B/P: 130/87, R: 18, O2 SAT:
98% RA, and Pain Scale: 6/10.
His lower extremities demonstrate
2+ pitting edema.
Assessment
1. Obtain history and
physical assessment with
vital signs.
2. Note location and severity
of edema.
3. Note personality changes
and restlessness.
4. Monitor 24-hour intake
and output balance.

Decrease Stressors and/or
Strengthen Lines of Defense
1. EstabIish fIuid intake
scheduIe, incorporating
preferences when
possibIe.
2. Change position
frequentIy; eIevate feet
when sitting.
3. Administer medications
as scheduIed.

Teaching CounseIing
1. Encourage verbalization
of feelings regarding
limitations.
2. Teach the patient a
proper diet and amount of
fluid intake in order to
prevent future fluid
overload.
3. Teach client to record his
weight properly (same
time everyday) in order to
record the amount of fluid
he is losing/gaining daily.

Assessment Rationales 1-4:
1. History and physical
with vital signs
establishes a baseline
for the patient.
2. Edema is fluid and can
cause more problems
with circulation and
mobility.
3. Personality changes
and restlessness are
signs of cerebral edema
or electrolyte
imbalances and need to
be treated immediately.
4. Diuretic therapy may
result in sudden or
excessive fluid loss
even though edema
may still be present.
(Doenges, Moorhouse, & Murr,
2010, Pg.57-58).

Decrease Stressors
RationaIes:
1. nvolving client in
regimen may enhance
sense of control and
cooperation with
restrictions.
2. Edema formation,
slowed circulation, or
bed rest are stressors
that affect skin integrity.
3. Diuretics increases rate
of urine flow and may
inhibit reabsorption of
sodium and chloride in
the kidneys.
(Doenges, Moorhouse, & Murr,
2010, Pg.57-58).

MeasurabIe and ReaIistic
Outcomes
O Short Term
Client will demonstrate stabilized
fluid volume with balanced intake
and output by the end of my shift
10pm on 11/21/11.

O Long Term
Client will verbalize
understanding of individual
daily fluid restriction of 1000
mL by his discharge date.

Short Term Outcome: ***x** Met ***** Partially Met ***** Not
Describe: Client kept his fluids under 1000 mL and had an equal amount of output as his intake.
Client reassessed and admitted his symptoms have improved.

NUR1211CSYLLABUS/COURSEOUTLNEOCTOBER2011/PYC
FALL 2011
SYW

Long Term Outcome: ***x** Met ***** Partially Met *****Not Met
Describe: Client verbalized understanding of his therapy regimen and if demonstrating proper
fluid intake according to his fluid restriction schedule.

Nursing Process Report Form
FORM #9

Nursing Diagnosis (R/T and
AEB): Activity ntolerance
related to abdominal muscle
weakness as evidenced by
exertional dyspnea and verbal
reports weakness and
exhaustion.
Nursing Interventions Scientific RationaIe
(incIuding references)
Assessment Data
O Subjective Assessment
Client states that he has difficulty
breathing and short of breath
when he walks and does light
activities.

O Objective Assessment
Client's vital signs are BP:
130/87, T:97.6, R:18, HR: 83, O2
Sat: 98%, pain: 6/10. Clients
breath sounds are diminished.
Assessment
1. Obtain vital signs every
4 hours.
2. Evaluate client's
response to activity.
3. Observe for pressure
ulcers.

Decrease Stressors and/or
Strengthen Lines of Defense
1. Have the patient do
relaxation exercises.
2. Perform ROM exercises
to all extremities every
2-4 hours.
3. Turn and reposition
every 2 hours.

Teaching CounseIing
1. Teach the importance of
breathing exercises.
2. Teach the patient the
importance of abiding to
his health regimen.
3. Teach him energy
conservation techniques
(Sitting instead of
standing to do some
activities, pacing
activities, and taking
short rest periods
between activities.

Assessment RationaIes 1-3:
1. Vital signs should return
to normal within 2-5
minutes after stopping
exercise.
2. Establishes client's
capabilities and needs
amd facilitates choice of
interventions.
3. ncreased bedrest will put
the client at risk for
pressure ulcers.
(Doenges, Moorhouse, & Murr,
2010, Pg. 130-131).

Decreases Stressors
RationaIes:
1. Relaxation can help the
patient reduce anxiety
and prevent
hyperventilation.
2. ROM exercises foster
muscle strength and tone,
maintain joint mobility,
and prevent contractures.
3. Turning and repositioning
prevent skin breakdown
and improve lung
expansion and prevent
atelectasis.
(Doenges, Moorhouse, & Murr,
2010, Pg. 130-131).

MeasurabIe and ReaIistic
Outcomes
O Short Term
Client will ambulate from the bed
to chair for meals twice during my
shift, before 10pm on 11/21/11.

O Long Term
Client will demonstrate an
increase in tolerance to activity
with absence of dyspnea by his
discharge date.

Short Term Outcome: **x*** Met ***** Partially Met ***** Not
Describe: With my assistance, client ambulated from the bed to the chair for meals with minimal
distress.

NUR1211CSYLLABUS/COURSEOUTLNEOCTOBER2011/PYC
FALL 2011
SYW

Long Term Outcome: ***** Met **x*** Partially Met *****Not Met
Describe: Client is demonstrating an increase in tolerance but still experiences dyspnea.


References

Berman, A., Snyder, S., Kozier, B., & Erb, G. (2008). Fundamentals of Nursing:

Concepts, process, and practice (8th ed.) Upper Saddle River: Pearson Prentice
Hall.

Corbett, J. (2008). Laboratory tests and diagnostic procedures: With nursing

diagnoses (8th ed.) Upper Saddle River: Pearson Prentice Hall.

Deglin, J. H. & Vallerand, A. H. (2011). Davis's drug guide for nurses (12th ed.)

Philadelphia: F.A. Davis Company.

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2010) Nursing care plans; Guidelines

for individualizing client care across the life span. Philadelphia, PA: F.A. Davis

Company.

gnatavicius, D., & Workman, M. (2010). Medical-surgical nursing Critical thinking for

collaborative care (6th ed.) St. Louis: Elsevier.