LaGuardia Community College
City University of New York
Department of Applied and Natural Science
Practical Nursing Program
DOCUMENTION OF THE NURSING PROCESS
STUDENT NAME: Anaïse
Ikama
DATE: 07/19/07
MEDICAL DIAGNOSIS: Stroke
CLIENT’S INTIALS: W.
E.
INSTRUCTOR:
CLIENT CARE OBJECTIVE (S): Help
and improve client’s memory loss; Keep client free from fall
ASSESSMENT
(SUBJECTIVE/OBJECTIVE)
Data Collection
CLIENT’S PROBLEM
(S)/NEED(S)
(USE NURSING DIAGNOSIS
STATEMENTS)
CLIENT SHORT TERM
GOAL/OUTCOME
(PLANNING)
NURSING
INTERVENTION
(APPROACH)/ (ACTION)
SCIENTIFIC RATIONALE
FOR
NURSING INTERVENTION
An 83-year-old black
African American woman
was admitted on June 21,
07 with a left side
cerebrovascular accident.
A- Impaired Memory
related to neurological
disturbances as
manifested by inability to
orient to place, time and
person.
a- Client will demonstrate
use of techniques to help
with memory loss.
1- Assess cognitive
function and memory by
using tools such as the
Mini-Mental State
Examination (MMSE).
2. Determined the client’s
blood sugar level.
3- Evaluate all medications
that the client is taking to
determine whether they
are causing the memory
The MMSE can help
determine whether the
client has a cognitive
impairment and or
memory loss, delirium
and needs to be referred
for further evaluation and
treatment.
Client has a medical
history of hypertension,
cerebrovascular accident
and dementia. Client has
allergy to penicillin and is
b- Client will state has
improved memory for
every day concerns.
Elevated blood sugar
level were associated
on fall precaution.
loss.
Client’s current diagnoses
are: stroke and altered
mental status.
On Thursday 12, 07,
received patient in bed.
Client was not orientated to
place and time with a Foley
catheter, which she
received at bedside on
07/09/07. Monitored vital
signs: BP 167/89; P 60;
RR 18 and T 96.8
with impaired memory
Many medications,
prescription and over the
counter may cause
memory loss in the
elderly.
B- Risk for fall related to
visual difficulty and
impaired physical
mobility as evidenced by
inability to walk from bed
to shower.
a- Client will remain free
of fall
b- Client will explain
methods to prevent injury
1- Screen client for stability
and mobility skills (supine
to sit, sitting supported and
unsupported and
standing…)
2- Place a fall prone client
in a room that is near the
nurses’ station.
3- Routinely assist the
client with toileting on his
or her own schedule
It is helpful to determine
the client’s functional
abilities and then plan for
ways to improve problem
areas and determine
methods to insure safety.
Such a placement allows
more frequent
observation of the client.
The majority of falls are
related to toileting. It’s
more acceptable to fall
than to “wet yourself”