Name:
Date:
Assignment:
1. Lab Values Check-up
Lab
Normal Range
Increase Value S/S
Decrease Value S/S
Na (Sodium)
135-145 mEq/L
Confusion
Muscle weakness
K (Potassium)
3.5-5.0 mg/L
Heart palpitations
Muscle cramps
Chloride
98-106 mEq/L
Muscle spasms
Difficulty breathing
Creatinine
Females: 0.5-1.1
mg/dl
Males: 0.6-1.2mg/dl
Elevated blood
pressure
Decreased mobility
Hemoglobin
Females: 12-16 g/dl
Males: 14-18 g/dl
Hyperhidrosis
Pallor skin
Hematocrit
Females: 37-47%
Males: 42-52%
Vision impairment
Irregular heart beat
Magnesium
1.3-2.1 mEq/L
Respiratory distress
Hyperexcitability
Calcium
9-10.5 mg/dl
Muscle twitching
Numbness/tingling
Platelet
140,000-400,000
Chest pain
Excessive bruising
Dehydration
Overhydration or
Polydipsia
<6%
Polydipsia
Jitteriness/trembling
10-20mcg/mL
Nystagmus
Confusion
0.5-2.0 ng/ml
Heart palpitations
Shortness of breath
Normal urine specimen 1.005-1.030
Hemoglobin A1C
Dilantin therapeutic
level
Digoxin therapeutic
level
**Lab references and signs and symptoms located on page 226 through 261 in Brunner and
Suddarth’s textbook of Medical- Surgical nursing
2. Fish-boned
3. 20 Nursing diagnosis - 3 nursing intervention & rationales.
Nursing Diagnosis
1. Urge urinary
incontinence
Nursing Intervention & Rationale
1. Treat underlying physiological conditions.
Infection/sepsis is treated with antibiotics. Discontinue
medications that cause an adverse reaction. Correct
abnormal electrolyte imbalances. Treat high or low blood
glucose.
2. Limit stimuli.
Overstimulation can worsen confusion, anxiety, and
agitation. Keep the room quiet and eliminate noise such as
the TV. Provide undisturbed rest periods. Allow family to visit
only if it comforts the patient.
3. Prevent sundowning.
Maintain a routine for waking, meals, bedtime, and activities.
Provide plenty of exposure to light. Limit daytime napping.
Provide familiar items such as photographs or blankets.
2. Acute confusion
1. Orient the patient as necessary.
Continuous and frequent reorienting may be necessary to
prevent agitation and fear. Reorient to staff, surroundings,
environment, and procedures. Do not challenge illogical
thinking as this can worsen delirium and anxiety.
2. Implement safety measures.
Patient safety is a top priority. Patients who are restless or
paranoid due to confusion may behave in unsafe ways. Keep
the bed in a low position with the alarm on, and the call bell
within reach to prevent falls.
3. Limit stimuli.
Overstimulation can worsen confusion, anxiety, and
agitation. Keep the room quiet and eliminate noise such as
the TV. Provide undisturbed rest periods. Allow family to visit
only if it comforts the patient.
3. Risk for unstable
glucose
​1. Have patient bring glucose monitor and demonstrate
use.
Ensure the monitor is working properly and then observe the
patient checking their glucose. Ensure they are performing all
steps of the fingerstick correctly.
2. Have patient demonstrate insulin administration.
Ensure they understand how to draw up their insulin (or use
the dial on an insulin pen) and that they are rotating
subcutaneous fat sites and cleaning the site before injection.
3. Recommend keeping a glucose level log.
Provide the patient with a form or instruct to use a notebook
and write down their glucose levels every day. This will help
the provider understand any patterns and the need for any
treatment changes.
4. Disturbed body
image
1. Educate the patient on healthy coping patterns.
Patients with disturbed body image may have unhealthy
coping patterns. Educating the patient on healthy coping
patterns will allow the patient more control and
independence in their daily life.
2. If weight loss or gain is needed create a weight graph.
This will allow the patient a visual in how s/he is progressing
towards her/his goal.
3. Identify and encourage the patient to participate in
community support groups.
Community support groups can help motivate patients and
decrease their loneliness and isolation.
5. Risk for injury
Implement fall precautions as appropriate.
Patients at an increased risk of falling are also at an
increased risk of injury. By identifying patients that are at an
increased risk of falls the nurse can implement measures to
prevent falls from occurring initially.
Provide safe environment (remove tripping hazards such
as rugs or anything on the floor, remove any cords in
walking way)
Providing a safe environment for patients will decrease the
risk of potential injuries.
Monitor mental status.
Altered mental status could increase a patient’s risk of injury
as the patient may not be fully aware of their surroundings
and what is considered safe
6. Imbalanced
nutrition
Provide nutritional supplements as appropriate or
ordered.
The RN should ensure the patient is receiving and taking
these supplements to further strengthen the body.
Provide the patient with resources regarding nutrition.
The patient will be able to take these resources home upon
discharge and will further help in the patient being
independent in their care.
Educate the patient on the body’s nutritional needs.
This will allow the patient to gain knowledge in the area of
how to independently care for oneself upon discharge.
7. Risk for infection
1. Limit visitors and/or use protective isolation for patients
who are at risk for infection.
Reducing visitation reduces the chance of spreading
pathogens to the patient.
2. Teach the patient, family, and caregivers signs and
symptoms of infection and when to contact a healthcare
provider.
It is important to recognize signs of infection early in order to
seek prompt treatment.
3. Encourage the intake of calorically dense and protein rich
foods.
The immune system is more responsive and effective when
nutritional status is sufficient.
8. Impaired skin
integrity
1.Perform wound care per guidelines and orders
Wound care differs depending on the type of skin
breakdown, location on the body, and size of the wound.
Inadequate or incorrect wound care delays healing and
increases the risk for infection.
2. Complete skin assessment
A thorough head-to-toe skin assessment should be
performed on admission, transfer between units, and once
per shift to monitor and/or prevent skin breakdown.
3. Ensure socks or non-slip footwear is worn at all times
Due to decreased sensation to the lower legs and feet, the
patient must keep feet protected to prevent skin injury.
9. Risk for unstable
blood glucose
level
1. Have patient bring glucose monitor and demonstrate
use.
Ensure the monitor is working properly and then observe
the patient checking their glucose. Ensure they are
performing all steps of the fingerstick correctly.
2. Have patient demonstrate insulin administration.
Ensure they understand how to draw up their insulin (or use
the dial on an insulin pen) and that they are rotating
subcutaneous fat sites and cleaning the site before
injection.
3. Recommend keepinga a glucose level log.
Provide the patient with a form or instruct to use a notebook
and write down their glucose levels every day. This will help
the provider understand any patterns and the need for any
treatment changes.
10. Risk for infection
1. Limit visitors and/or use protective isolation for patients
who are at risk for infection.
Reducing visitation reduces the chance of spreading
pathogens to the patient.
2. Teach the patient, family, and caregivers signs and
symptoms of infection and when to contact a healthcare
provider.
It is important to recognize signs of infection early in order to
seek prompt treatment.
3. Encourage the intake of calorically dense and protein
rich foods.
The immune system is more responsive and effective when
nutritional status is sufficient.
11. Ineffective airway
clearance
1. Assess lung sounds.
Diminished lung sounds or adventitious lung sounds such as
wheezing, stridor, rhonchi, or crackles can result from an
accumulation of secretions or a blocked airway.
2. Assess respirations.
Note the rate, depth, pattern, and use of accessory muscles
when breathing. Increasing rate, nasal flaring, and accessory
muscle use is an attempt to compensate for ineffective
breathing.
3. Evaluate the ability to swallow or cough.
Assessing the patient’s gag reflex and ability to cough and
swallow will determine their ability to protect their airway and
guide further interventions.
12. Insomnia
1. Assess sleep patterns.
Assess when the patient normally goes to bed, what time
they wake up, how long it takes them to fall asleep, and how
many times they wake up during the night to provide baseline
data.
2. Identify poor sleep hygiene behaviors.
The use of electronics before bed, napping during the day,
irregular bedtimes, caffeine intake too late in the day, and
sedentary lifestyles contribute to inadequate sleep.
3. Assess the use of stimulants or drug abuse.
Overuse of caffeine or the abuse of stimulants whether
prescribed or not affects sleep patterns. The abuse of
nicotine, alcohol, or drugs can cause insomnia.
13. Risk for aspiration
1. Keep suctioning equipment at the bedside.
Patients at an increased risk for aspirating should have
functioning suctioning equipment at the bedside for
immediate use.
2. Performing suctioning as necessary.
Patients with a large amount of secretions or who cannot
clear them themselves may require frequent suctioning.
3. Keep the head of the bed elevated after feeding.
Whether self-feeding, assisting with feeding, administering
medications or tube feedings, the head of the bed should
remain elevated for 30 min-1 hour after.
14. Fluid volume
deficit
1. Administer intravenous hydration if needed.
Severely dehydrated patients or patients unable to take oral
hydration may require IV hydration to maintain appropriate
hydration level.
2. Educate patient and family on possible causes of
dehydration.
Education will help allow the patient and family to have a
better understanding of the diagnosis and preventative
measures they can take in the future to avoid dehydration.
3. Administer electrolyte replacements as needed/as
ordered.
Dehydration can lead to electrolyte abnormalities, it is
important the nurse monitors for this and provides
supplemental replacements when needed.
15. Impaired airway
clearance
1. Assess lung sounds.
Diminished lung sounds or adventitious lung sounds such as
wheezing, stridor, rhonchi, or crackles can result from an
accumulation of secretions or a blocked airway.
2. Assess respirations.
Note the rate, depth, pattern, and use of accessory muscles
when breathing. Increasing rate, nasal flaring, and accessory
muscle use is an attempt to compensate for ineffective
breathing.
3. Evaluate the ability to swallow or cough.
Assessing the patient’s gag reflex and ability to cough and
swallow will determine their ability to protect their airway and
guide further interventions.
16. Anxiety
1. Acknowledge the feelings the patient is experiencing.
Acknowledging the patient’s feelings will help the patient feel
she or he is being heard and can assist the patient in
becoming more trusting and comfortable with the nurse.
2. Administer medication as appropriate and as ordered.
Individuals with a history of anxiety may have PRN anxiety
medications to assist with breakthrough anxiety/panic
attacks.
3. Instruct patient through guided imagery or other
relaxation techniques/methods.
This will promote relaxation for the patient and the release of
endorphins that will further reduce anxiety
17. Knowledge deficit
1. Create a quiet learning environment.
Teaching should not be attempted in certain situations. If a
patient is in pain, worried, upset, or tired then they are not in a
state of mind to retain information. The nurse should wait
until the patient can concentrate on what is presented to
them without interruption.
2. Include the patient in their plan.
Telling a patient what they should or shouldn’t do will not
necessarily guarantee adherence. Creating a plan that fits the
client’s lifestyle will ensure the highest chance of adherence
and motivation.
3. Use multiple learning modalities.
After establishing how the patient learns best, offer choices.
Verbal instructions along with written materials, instructional
videos, and illustrations are a few options.
18. Impaired verbal
communication
1. Use aids and devices.
Assistive devices such as text-to-speech, TTY or TDD assists
those with speech impairments. Picture boards and other
apps can help children communicate.
2. Sign language.
Nurses can implement important words and phrases into
their profession to communicate with patients. Commonly
used phrases in the hospital such as “pain” “bathroom” or
“water” can be useful to learn.
3. Use an interpreter.
An interpreter should always be used when communicating
with a patient who does not speak the nurse’s language.
19. Impaired comfort
1. Administer medications to ease discomfort.
Pain medications, antiemetics, and antianxiety medications
are necessary to increase comfort and improve rest and
healing.
2. Consider nonpharmacologic interventions.
Warm blankets can increase comfort. Cool rags can ease
nausea or feeling overheated. Pillows and repositioning
prevent physical discomfort.
3. Explain procedures and care before implementing.
Patients are often at the mercy of others and can feel
vulnerable when sick and hospitalized. The nurse should
always explain everything they do before they do it.
20. Activity
intolerance
1. If patient is limited to bed-rest, begin with range of
motion (ROM) exercises.
It is important to adapt activity exercises to patient’s current
tolerance level and build from there.
2. Monitor vital signs throughout activity.
This ensures patient is remaining in a stable state throughout
activity.
3. Provide supplemental oxygen therapy as needed.
Patients with decreased activity tolerance may become short
of breath with activity and require additional oxygen therapy
in order to maintain appropriate oxygen saturation levels.
References: NANDA International Nursing Diagnoses:
Definitions & Classification, 2021-2023 12th Edition
by T. Heather Herdman, Shigemi Kamitsuru and Camila
Lopes