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Student Name: Robyn Begalke

1045075

Nursing Assessment Form

Client Name: C.M. Medical Diagnosis: SEE PATHOLOGY RECORD

Client Perception of Health Needs: Unable to determine, states “I’m okay”

Client Goals for Health: Unable to determine, states “I’m okay”

Allergies (food, medication, environmental)

No known allergies.

Medications SEE MEDICATION RECORD

Dietary considerations

- High protein/high calorie, easy to chew diet with 60ml Resource 2.0 with all meals and his evening snack

- Needs to be set up and will eat better with encouragement- He requires assistance to eat- Fluids are regular (thin) – has no problem swallowing fluids but has

difficulty chewing his food and often pockets- Receives 375 ml of cranberry juice with every meal for UTI

prevention- Is lactose intolerant but gets 125ml of soy milk with every meal- Is currently on a soft easy to chew diet but intake is much better when

he receives a minced diet. Requisition for dietary to change his diet is in process

Vital SignsT 37.0 tympanic

P 60 weak and irregular (radial)

R 14 shallow and unlabored

BP 110/62 lying flat

O2 sats 94% on room air

Pain rating 0

HEALTH ASSESSMENT DATA

Physiological Variable


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General Appearance/Mental State:Male. 78 years old. English speaking. Grey hair, scruffy face, thin, with a newspaper in hand (always). Lying slouched in bed with a pillow folded in half to support his neck. Loud and verbal, and maintains eye contact well when spoken to directly. Smiles often when smiled at. Looks very relaxed. Always covered up to his chest with blankets. Skin is relatively moist with some minor dry areas. Wears a gown all day and doesn’t dress into day clothes. Generally cooperative after some encouragement. Speaks coherently and understands speech. Doesn’t speak much unless asked questions. Oriented to person and place. Refuses to participate in community activities. Repeats himself often and has poor recollection of short term memory.

Cardiovascular System:- Has been diagnosed with benign

hypertension- BP: 110/62 lying flat, P: 60 weak and

irregular (radial)- Apical pulse 60, strong and irregular- S1 and S2 sounds identified on all

cardio sites with no additional sounds- Heart sounds are muffled- Radial, ulnar, carotid, brachial and

popliteal pulses palpable- Dorsalis pedis unpalpable- All extremities are pink and warm to

touch- Capillary refill <2 seconds


1045075


Respiratory System:- 14 respirations per minute shallow and

unlaboured- SPO2 of 93% on room air- Lung sounds clear in right and left

upper and lower lobes bilaterally- Fine crackles noted in right middle

lobe- Symmetrical chest expansion- Bronchial, bronchovesicular and

vesicular sounds normal- No cough presently

Gastrointestinal System:- Patient refuses meals on a regular basis- Needs encouragement to eat well- Appears hydrated, skin turgor < 2

seconds, no tenting noted, lips mucous membranes pink and moist

- Bowel sounds noted in all 4 quadrants- Often needs suppository to alleviate

constipation- Abdomen soft with no distension- Has bowel incontinence and wears a

large brief- Fluid intake is good, usually at least

250ml per meal and drinks periodically throughout the day

- W: 63.6 kg, H: 188.0 cm- BMI of 18 = underweight. Needs to

gain 1.9 kg to be at normal body weight

Urinary System:- Indwelling Foley catheter due to

diagnosis of BPH- 14 Fr Foley catheter, 5cc silicone

coated, 10 ml balloon inflation- Urine is light amber with large amount

of sediment- No bladder distension noted- Uncomfortable during catheter care as

evidenced by constant requests to be covered up

- It is normal for this client to have sediment in his urine

- Intake and output is monitored daily

Sensory Systems:- Doesn’t wear prescription or reading

glasses- No hearing aid but must speak loudly- No signs or symptoms of peripheral

neuropathy- Able to communicate well with no

delay in speech


1045075


Nervous System:- Alert and oriented to person and place- GCS of 15- Pupils are approximately 2mm, equal

and reactive to light- No facial nerve deficit- No paralysis and feeling in all

extremities- No tremor noted- Occasionally confused due to

Alzheimer’s dementia- Often loss of short term memory- Denies pain- Sleeps well through the night- Tympanic temperature 37.0

Integumentary System:- Skin pink and warm to touch- Skin generally moist with some areas

of dry skin- Thin hair on scalp and very little hair

on arms/legs bilaterally- Skin turgor of < 2 seconds and no

tenting noted- Braden score of 12: high risk- History of pressure ulcers to both heels

and coccyx- Currently has 2 stage 2 pressure ulcers

on coccyx (2.5 x 0.5 x 0.2 cm) and (0.5 x 0.5 x 0.1cm)

- Currently has unstagable pressure ulcers on heels bilaterally

- Wears boots on both feet to prevent pressure ulcers on heels


1045075


Musculoskeletal System:- Limited mobility in all extremities and

unable to reposition or transfer independently

- Able to flex, extend and circumduct with arms bilaterally

- Unable to move up in bed or sit up without assistance

- Unable to weight bear or ambulate without 2 person assist

- Weak against resistance- History of falls (2 in 2014) before

being admitted- Decrease in muscle mass since

admission- T8/T10 compression fractures- No exercises/activities at this time per

occupational therapy

Reproductive System:- Has one 3 children and 8 grandchildren- Has been diagnosed with Benign

Prostatic Hyperplasia- Indwelling Foley catheter

Endocrine System:- Client is able to regulate hormones

without pharmacological intervention

Client Resuscitation Status:C2 – Terminal care. Diagnosis will cause eventual death, efforts are aimed at symptom control, no resuscitation, surgery is not appropriate, life sustaining measures should be discontinued unless necessary for comfort, life support interventions should not be initiated.


1045075


Spiritual Variable (Environment)- Client does not practice religion- Refuses to attend community church

services- Loved to spend his time in nature;

hunting, fishing, bird watching and hiking, which he remembers as being very peaceful.

Developmental Variable (Environment)- Client is in the ego-integrity vs. despair

stage of development according to Erik Erikson’s theory of development.

- Client is on the ego-integrity end of the spectrum. He reflects on his life and feels accomplished and pride for what he’s achieved and loves to talk about his career and family. The client is not depressed or fearful and is generally content with his life.

Sociological Variable (Environment)- Client enjoyed 1:1 company with

recreational therapists but hasn’t participated since December 2014

- Eats alone in room- Spends time alone in room reading the

newspaper- Has a roommate but doesn’t converse

with him- Has occasional visits from family

members

Psychological Variable (Environment)- Graduated university with a bachelor

of science in forestry- Spends most of his time alone or with

the health care staff- Married with kids and grandkids but

doesn’t see them often- Refuses care often- Diagnosed with Alzheimer’s dementia

so often cannot recall short term memories

- Likes to be in control of situation so often feels vulnerable

Determinants of health impacting client’s health (Environment)- Client is bed bound- Inability to perform daily activities without extensive assistance- At risk for infection, impaired skin integrity, emotional distress, loneliness- Social isolation from family- Inability to recall recent events may impede his ability to report symptoms


1045075


Interdisciplinary Team Members- Physician- RN, LPN, SPN- Dietary- HCA- Occupational Therapy

Health Priorities- To remain free of infection- To maintain skin integrity and heal current pressure ulcers- To ensure adequate nutrition and intake of fluids- To keep pain to a minimum- To provide client with companionship when able

Client Strengths- Friendly and communicates well- Cooperative if encouraged with scotch mints- Smiles often- Enjoys to read- Good sense of humour- Is helpful with care with the right encouragement

Laboratory/Radiology ReportsLast/only lab results, October 14, 2014- GFR: 87 umol/L Good. Range is > 59 (used to determine kidney function)

Student Name: Robyn Begalke 1045075

Pathophysiology Record

Must be written in your own words (i.e., as if teaching a patient)

Medical Diagnosis Pathophysiology Signs and Symptoms ComplicationsAlzheimer’s Dementia Alzheimer’s disease is the most

common cause of dementia (which is characterized by memory loss, confusion, difficulty with problem solving and language). Alzheimer’s is a progressive disease of the brain in which proteins build up and form structures called ‘plaques’ and ‘tangles’, people with Alzheimer’s may also experience a loss in some important chemicals in the brain. These conditions together cause the loss of connections between nerves, leading to nerve cell and brain tissue death.

Memory lapses, difficulty finding the right word in conversation (expressive aphasia), getting lost in a familiar place, mood changes, hallucinations, impaired judgment and impaired perception.

Abnormal brain function can lead to physiological complications such as dysphasia and urinary incontinence. Patients who suffer from this disease may also be unable to report symptoms they may be experiencing that could indicate other conditions. They may also be more susceptible to pneumonia due to dysphasia.

Benign Hypertension Hypertension is consistent high blood pressure of 140/90. It is usually caused by an increase in blood volume being pumped throughout the body causing the arteries to become less elastic. Benign hypertension is usually over a prolonged period of time

Headache, blurred vision, nausea, weakness, confusion, fatigue and change in mental status

Cardiovascular disease, stroke, damage to the heart, kidneys and eyes.

Student Name: Robyn Begalke 1045075and escalates more slowly than malignant hypertension. It is generally asymptomatic, but will likely cause similar complications as malignant hypertension and can present with the same symptoms.

Benign Prostatic Hyperplasia (BPH)

BPH is an enlarged prostate gland. The prostate gland surrounds the urethra in male patients and may block or partially block the regular flow of urine. It is believed to be caused by the normal aging process and decrease in testosterone.

Difficulty starting a urine stream (hesitancy), decreased strength of urine stream, dribbling after urination, feeling that the bladder is still full after urination (retention), the urge to urinate after urination (urgency), painful urination (dysuria).

Sudden inability to urinate (blockage of the urethra), Urinary tract infections (UTI’s), bladder stones, bladder infection, kidney damage.

Hyperlipidemia We have natural fats in our body that are essential for supplying and storing energy. These fats are called lipids, more commonly known as cholesterol levels. With hyperlipidemia, the lipids or fats can buildup in the arteries that may lead to a partial or full blockage that can affect blood flow to the vital organs.

Chest pain, cramping in one or both calves while walking, sores on the toes that do not heal, sudden stroke like symptoms including one side of the face to droop, trouble speaking, weakness of one arm or leg, and loss of balance

Hardening of the arteries, a buildup of fats that can cause deficient blood flow and can lead to a stroke or myocardial infarction or heart attack.

Student Name: Robyn Begalke 1045075At risk for infection related to indwelling Foley catheter.

Client goal: Client will remain free of infection.

Client outcome: Client will remain free of infection as evidenced by temperature within normal range, adequate output and no report of painful urination during the next two weeks in my care.

1) Ensure there are no obstructions or blockages in the catheter tubing on a daily basis to prevent the backflow of urine up the tubing and/or re-entering the bladder. (Potter & Perry, 2014, p. 626)

2) Empty the drainage bag every shift and note output, color, consistency and odor of urine. (Potter & Perry, 2014, p. 1148)

3) Encourage adequate fluid intake of at least 2000ml per day to flush the bladder (Potter & Perry, 2014, p. 1146)

1) Goal met. I have checked the catheter tubing everyday and have not noted any blockages or evidence of backflow. I will remain diligent in monitoring the tubing.

2) Goal met. I have emptied the drainage bag at the end of every shift and have kept a personal record of the quality of urine as well as documented the output.

3) Goal partially met. I have been able to ensure the client have an average intake of 1000ml per my 8 hour shifts. I would like to improve his intake to compensate for a decreased intake in the evening and HS.


Impaired skin integrity related to immobility as evidenced by two stage 2 pressure ulcers on coccyx and unstagable pressure ulcers on each heel.

Client goal: Client will have no further decline in skin integrity.

Client outcome: Client’s current pressure ulcers will not progress and client will have no incidence of new pressure ulcers during the two weeks in my care.

1) Ensure to keep the clients skin dry and clean well after bowel incontinence. (Potter & Perry, 2014, p. 1254)

2) Reposition the client every two hours to offload the pressure points. (Potter & Perry, 2014, p. 1254)

3) Document and report any changes or abnormal findings in skin condition. (Potter & Perry, 2014, p. 1254)

1) Goal met. I have been diligent in changing the clients brief as early as possible after breakfast to ensure that he is not wearing a soiled brief for a lengthy period of time. I have also made sure that his bottom is dry before securing the new brief. This intervention has been effective.

2) Goal met. I have been able to place a pillow under alternating hips every 2 hours during my shift to offload the coccyx. The pressure ulcers have not progressed and remain at a stage 2 at this time.

3) Goal met. I have reported any changes in the clients skin condition and have been able to get the wound care protocol updated for his coccyx ulcers, which will improve their ability to heal.


Dysfunctional gastrointestinal motility related to immobility evidenced by frequent constipation and regular laxative administration.

Client goal: Client will have regular bowel movements.

Client outcome: Client will have at least one bowel movement every one to two days within the next two weeks in my care.

1) Ensure that the client is taking in 1500-2000 ml fluids per day to increase water content within the gastrointestinal tract to promote peristalsis. (Potter & Perry, 2014, p. 1178)

2) Encourage the client to eat most of his meals to increase or maintain his level of fibre intake. Fibre acts “like a sponge” to encourage waste through the bowels. (Potter & Perry, 2014, p. 1179)

3) Monitor for, assess and report any abdominal distension or decreased bowel sounds. (Potter & Perry, 2014, p. 1178)

1) Goal met. Client is taking in an average of 1000ml per my 8 hour shift. This intervention has been effective if the client is able to maintain at least 500ml of fluid intake during the evening shift.

2) Goal partially met. I have been able to encourage the client to eat >75% of his breakfast and lunch meals. I would like to improve his intake, but it is improved from his previous 50% intake

3) Goal met. I have performed a gastrointestinal assessment everyday and have not noted any abnormal findings thus far.

Student Name: Robyn Begalke 1045075Medication Research Record

Ensure you relate the medication information to the appropriate medical diagnosis. Please use lay terms as if you were teaching a patient.

Medication/Reason for Medication Order

Dosage/Safe Dose

Action as Related to Medical Diagnosis

Common Side Effects Nursing Implications

Generic: Dutasteride

Trade: Advodart

Class: Androgen inhibitor (for BPH)

Dose ordered: 0.5mg PO daily

Safe dose: 0.5mg PO once daily

Blocks the ability of testosterone to become active to decrease the size of the prostate gland.

Depressed mood, prostate cancer, erectile dysfunction, testicular pain or swelling, rash, angioedema (rapid swelling of deep layers of skin)

Assess patient for signs and symptoms of urinary retention, urgency or hesitancy, or dysuria. Do not break, crush or chew the capsule.

Generic: Potassium Chloride

Trade: Apo-K

Class: Mineral/electrolyte replacement

Dose ordered: 20 mEq PO at breakfast daily

Safe dose: for normal daily requirements: 40-80 mEq PO daily, for prevention of hypokalemia with diuretic therapy 20-40 mEq PO daily

Acts as the natural electrolyte potassium essential for nerve impulses, contraction of cardiac, skeletal and smooth muscles, gastric secretion and renal function.

Confusion, restlessness, weakness, arrhythmias, abdominal pain, diarrhea, flatulence, nausea, GI ulceration, paralysis

Assess for signs and symptoms of hypokalemia (dizziness, muscle weakness, arrhythmia, hypotension, thirst) and hyperkalemia (cardiac arrest, abdominal cramping & flaccid paralysis), monitor serum potassium, administer with or after meals to decrease GI upset, administer with a full glass of water, do not crush or chew enteric coated tablets.

Student Name: Robyn Begalke 1045075Generic: Tamsulosin

Trade: Flomax

Class: Peripherally acting antiadrenergic

Dose ordered: 0.8mg PO at bedtime

Safe dose: 0.4mg PO once daily after meals, may be increased to 0.8mg PO daily after 2-4 weeks

Decreases the smooth muscle contraction of the prostate gland decreasing the symptoms of BPH including urinary urgency, hesitancy and nocturia.

Dizziness, headaches, rhinitis (irritation of the mucosa membrane in the nose), orthostatic hypotension

Assess patient for urinary urgency, hesitancy, retention and dysuria throughout therapy, monitor intake and output ratios and daily weight as well as edema. Administer daily dose 30 minutes after the same meal each day, administer capsules whole, do not crush or chew.

Generic: Acetaminophen

Trade: Tylenol)

Class: Non-opiod analgesic

Dose ordered: 650mg PO q 6 hours PRN

Safe dose: Safe dose: 325-650mg PO q 6 hours or 1g 3-4 times daily

When used for analgesia, relieves pain by increasing the pain threshold and decreasing inflammation and swelling

Hepatotoxicity, renal failure, rash, constipation

Administer with full glass of water, may be taken with food or on an empty stomach, monitor frequency of bowel movements

Generic: Bisacodyl

Trade: Dulcolax)

Class: Laxative

Dose ordered: 10mg sup per rectal daily PRN

Safe dose: 5-15mg/day up to 30mg/day

Increases fluid buildup in the colon and increases movement (peristalsis) in the intestines

Abdominal cramps, nausea, diarrhea, rectal burning, hypokalemia with chronic use, muscle weakness with chronic use

May be administered before bedtime for AM results, taking on an empty stomach will speed up onset, do not crush or chew enteric coated tablets, avoid administration within 1 hour of milk or antacid

Student Name: Robyn Begalke 1045075as a single dose

consumption, assess for bowel sounds, abdominal distension, colour, consistency and amount of stool excreted

Generic: Ipratropium Bromide

Trade: Atrovent

Class: Anticholinergic used as a bronchodilator

Dose ordered: 20mcg/dose, 2 puffs via chamber q 4 hours PRN

Safe dose: 2 inhalations 4 times daily (not to exceed 12 inhalations/24 hours or more frequently than q 4 hour). For acute exacerbations, 4–8 puffs using a spacer device as needed.

Dilates the airways in the bronchi and lungs to promote effective breathing and decreases mucous secretions.

Onset: 1-3 minutes

Dizziness, headache, blurred vision, sore throat, paradoxical bronchospasm, hypotension, palpitations, GI irritation, nausea, rash

Assess respiratory status prior to administration and at peak. When used concurrently with other inhalation medications, administer adrenergic bronchodilators first, then ipratropium, then corticosteroids with 5 minutes in between. Rinse mouth following administration.

Student Name: Robyn Begalke 1045075Generic: Metoclopramide

Trade: Maxeran

Class: Antiemetic

Dose ordered: 10 mg PO q 6 hours or may be given subcut

Safe dose: 10-15 mg PO 30 minutes before meals and at bedtime (do not exceed 0.5mg/kg/day)

Blocks the receptors in the brain that stimulate the feeling of nausea, and increases movement (peristalsis) in the upper GI tract.

Drowsiness, restlessness, anxiety, depression, irritability, arrhythmias, hypertension/hypotension, constipation, diarrhea and dry mouth.

Assess for nausea, vomiting, abdominal distension and bowel sounds before and after administration. Assess for signs of depression throughout therapy. Administer doses 30 minutes before meals and at bedtime.

Generic: Polythylene Glycol

Trade: Restoralax

Class: Laxative

Dose ordered: 17g PO daily

Safe dose: 17g in 8oz water may be used up to 2 weeks

Increases the absorption of water in the GI tract to promote bowel movements

Abdominal bloating, cramping, flatulence, nausea

Dissolve powder into 8oz of water prior to administration, assess for abdominal distension, presence of bowel sounds, and usual pattern of bowel movements, assess color, consistency and amount of stool excreted

Generic: Salbutamol

Trade: Ventolin

Class: Bronchodilator

Inhaler:Dose ordered: 100mcg/dose 2 puffs via chamber q 4 hours PRN

Safe dose: 2

Relaxes the smooth muscle of the airway (bronchi and lungs) to promote effective breathing.

Onset: 5-15 minutes

Nervousness, tremors, restlessness, insomnia, chest pain, palpitations, arrhythmias, hypertension, hyperglycemia, nausea, vomiting, hypokalemia

Assess lung sounds, BP and pulse before administration and during peak of medication, note amount and color of sputum produced. Prime the inhaler prior to administration, allow one minute between

Student Name: Robyn Begalke 1045075inhalations q 4-6 hours

Nebulizer:Dose ordered: 2.5mg via sidestream nebulizer q 4hours PRN

Safe dose: 2.5–10 mg q 1–4 hr prn;

inhalations, rinse mouth after administration. Use first when used concurrently with other inhalation meds, allow 5 minutes in between medications.

Generic: Sennosides

Trade: Ex lax

Class: Laxative

Dose ordered: 8.6mg PO every bedtime

Safe dose: 12-50mg 1-2 times daily

Increases the accumulation of fluid and peristalsis (movement) in the large intestine resulting in increased bowel movements

Cramping, diarrhea, nausea, pink-red or black-brown discoloration of urine, electrolyte imbalance

Ensure sennosides are taken with a full glass of water, administer at bedtime, may take 6-12 hours to take effect, administer on an empty stomach to speed up onset

Generic: Erythromycin

Trade: Erysol

Class: Macrolide anti-infective

Dose ordered: 4% topical in Lotriderm cream twice daily

Safe dose: 2% ointment twice daily

Inhibits the growth and reproduction of bacteria.

Ototoxicity, ventricular arrhythmias, nausea, vomiting, abdominal pain, diarrhea, hepatitis, rash

Cleanse area before application, wear gloves while applying, assess for infection throughout therapy, and monitor bowel function.

Student Name: Robyn Begalke 1045075Generic: Lactulose

Trade: Enulose

Class: Laxative

Dose ordered: 30ml PO q HS

Safe dose: 15-30ml/day up to 60ml/day

Increases the water content in the GI tract and softens the stool.

Belching, cramps, distension, flatulence, diarrhea

Assess patient for abdominal distension, presence of bowel sounds, and bowel patterns. Mix with other fluids to improve flavor, administer with a full glass of water or juice, may be administered on an empty stomach for rapid results.

Generic: Docusate Sodium

Trade: Colace

Class: Laxative

Dose ordered: 100mg PO twice daily

Safe dose: 50-400mg PO daily in 1-4 divided doses

Promotes the absorption of water into the fecal matter to soften the stool and prevent constipation.

Throat irritation, mild cramps, diarrhea, rashes

Administer with a full glass of water or juice, may be administered on an empty stomach for rapid results, do not administer within 2 hours of a laxative, assess for abdominal distention, presence of bowel sounds, and usual pattern of bowel function. Assess stool for amount, color and consistency.


1045075Nursing Care Plan - Summary

Describe the benefits of using the nursing process and the nursing concepts in your assessment and nursing care.

Assessment and Nursing Care

I was able to use the nursing process that I learned about in theory to guide my assessment and

nursing care. During the assessment phase of the nursing process, I gathered relevant information

to determine my client’s health priorities and to develop reasonable nursing interventions that

would make a difference in their quality of life. My knowledge of assessments has helped to

expand my critical thinking and clinical judgment. For example, during my head to toe

assessment of my client I was able to note my clients priority health concerns which led me to

my diagnosis phase of the nursing process; risk for infection, impaired skin integrity and

dysfunctional gastrointestinal motility. These nursing diagnoses led me to the planning stage of

the nursing process. I was able to develop reasonable and achievable goals as well as nursing

interventions for my client to improve or maintain their current level of health, such as increasing

fluid intake or repositioning to offload the client’s coccyx. The implementation of the nursing

interventions allows the goals to be met, and the goals wouldn’t have been made without the

information from the assessment and diagnosis phase. The nursing process works to benefit the

client and the nurse. Without the nursing process, the priority health concerns would be difficult

to determine and the nursing interventions would be much more difficult to develop. The

evaluation phase of the nursing process is so important because it allows the nurse to determine

if the nursing interventions were effective or not. If the interventions are not effective, the nurse

is able to return to the planning stage to come up with new interventions that will ensure the


1045075client outcome has been met. If I didn’t evaluate my interventions, I wouldn’t know that I need

to encourage even more fluid intake or that I should encourage even more consumption of his

meals. I am thankful that I was able to learn about the nursing process in theory and it is

fulfilling to see it in practice. It helps me to provide the best care for my client and to ensure that

his needs are being met. One nursing concept that has been incredibly beneficial for me to use is

effective communication. It was a different experience for me to interact with a client with

Alzheimer’s Dementia because I was never exposed to the disease process. I had to adjust my

communication style to improve my client’s level of comfort and understanding. I am grateful

for the experience and my communication requires improvement but I am finding it easier to

interact with him everyday.

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