1
Medical Diagnosis: Diverticulousis. Respiratory Failure,
Biographic Data:
Client’s Initials: M. D. Room: 34-05 D
Sex:
Surgical Procedure: None
Female
Date: N/A
Age: 72 years old
Religion: Unknown
Health History: Diverticulosis, Respiratory Failure,
Occupation: Retired Teacher
Incontinent Bowel, Incontinent Bladder
Admitting Date: 03/07/2007
Reason for Admission: Diverticulosis. Respiratory
Failure
Data: S= Subjective; O=Objective
NURSING DIAGNOSIS
(Indicate Source)
FORM PES STATEMENT
NURSE’S ACTION
(Implementation
Usual hours of sleep each night at home: Unable
The abscence of familiar stimuli and the
Fatigue r/t lack of sleep aeb
Keep enivroment quiet for
to assess. =O
presence of unfamiliar stimuli in the hospital,
client stating “I did not sleep sleeping, (e.g., avoid use of
Hours of sleep each night in the hospital: Unable
can prevent people from sleeping. (K&Ep.
a lot last night.”
intercoms, lower the volume on
to assess. = O
1117)
radio and television, keep beepers
on non audio mode, anticipate
Sleep disturbances (insomnia, enuresis,
sleepwalking): Unable to assess. =O
Sleep is a basic human need and is essential for
alarms on intravenous [IV] pumps,
health. When people are deprived of rest, they
talk quietly in unit.
Signs of sleepiness during the day (yawning, c/o
are often irritable, depressed and tired.
fatigue, irritability, dark circle under eyes, nap
during the day): Client stated through an
(K&Ep.1114)
Assess client for signs of
interpreter “I did not sleep a lot last night.” =S;
depression: depressed mood state,
Client was seen napping during the day. =O; Client
flat affect, statements of
was irritable during the day.=O
hopelessness, poor appetite.
LAGUARDIA COMMUNITY COLLEGE
City University of New York
SCR 110
NURSING ASSESSMENT PROCESS TOOL
Student: Louise Margaret Tomas
Date: November 15th, 2007
R
E
S
T
&
A
C
T
I
V
I
T
Y
ROM of joints of each extremity: ROM in both
upper extremities are good. ROM in L lower
extremity is good. Client has foot drop in R lower
extremity. =O
Muscular strength of each extremity: Muscular
strength in both upper extremities; and R lower
extremity are good. Muscle strength in L lower
extremity was poor; client was not able to move R
lower extremity.= O
Posture, gait, balance, coordination (include
coordination of hands): Client’s hand coordination was good; client was bed bound; gait
could not be assessed.= O
Degree of mobility (indicate): ability to walk,
ability to sit, ability to turn self or move in bed:
Client unable to turn self in bed without assistance.
=O
Assistive measures for ambulation or mobility:
Client is fully dependant to ambulate. = O
Level of activity prescribed:
Ability to perform ADL:
Cluster all factors that may affect mobility (pain,
traction, altered LOC, SOB, surgery, limited
Motion is essential for proper functioning of
bones and muscles. Limited range of motion
may cause the joints to be pulled into a flexed
position where the muscles shorten and the
joints become permanently fixed in a flexed
position. (K&Ep.1059& 1060)
Impaired physical mobility
r/t decreased muscle strength
and mass, aeb, paralysis,
limited ROM, inability to
perform ADL.
Perform passive ROM exercises
twice a day unless contraindicated.
Provide opportunities for
socialization and sensory
stimulation.
Ensure that the client is not over
sedated.
Individuals who are inactive because of illness
or injury are at risk for many problems that can
affect major body systems. (K&Ep. 1068)
Risk for disuse syndrome r/t
muscloskeletal inactivity,
deterioration of body systems
aeb altered LOC, immobility.
Observe the client's diet and
medication intake.
Perform ROM excersises.
Unused muscles atrophy, losing most of their
strength and normal function. (K&Ep. 1068)
Observe and document skin
integrity several times a day.
Mobility is an essential part of living. Mobility
Assess for constipation.
R.O. 8/03
2
ROM, decreased muscular strength, age,
paralysis):



is vital to independence. A fully immobilized
person is vulnerable and dependent. (K&Ep.
1059)
identify the factors that contribute
to undernutrition in hospital
patients.
Client was observed napping during the
day. =O
Limited ROM in R lower extremity. =O
Client unable to turn self in bed without
assistance. =O
Reposition client every 2 hours.
Perform ROM exercises
Physical activity produces progressive health
benefits, (K&Ep.1065) Activity affects mental
well being and the effectiveness of body
functioning. (K&Ep. 1059)
Position the client so that joints
are in the normal anatomical
alignment at all times.
The amount of ADL a client is able to perform
without experiencing adverse effects is related
to activity tolerance. (K&Ep.1065)
Reposition client every 2 hours
and observe skin
Monitor peripheral circulation.
Mobility can be affected by any disorder that
affects the respiratory system. (K&Ep. 1067)
Review drug profile for potential
side effects that may increase risk
of injury.
Identify all the clients medications
and ensure that all health care staff
have access to the information.
Carry out the 3 safety checks and
identify the 6 rights prior to
administering medications.
E
L
I
M
I
N
A
T
I
O
N
URINARY:
Voiding pattern: time, frequency, incontinent,
urgency, dysuria: Client is incontinent= O
Urine: quantity each voiding or amount in
bedside bag, clarity, color, odor, concentration:
Urinalysis: pH 4.8 (norm = 4.5-8 ), Specific
Gravity 1.02 (norm = 1.01-1.025 ), Blood
(norm =
), Protein (norm =
), WBC
(norm =
), Bacteria none present (norm =
none present ), Nitrites
(norm =
),
Leukocytes esterase
(norm=
)
Assistive measures for urination (foley catheter,
external sheath, suprapubic catheter, urinary
diversion)
Other factors that may affect normal urinary
elimination (immobility, meds fluid intake, poor
Incontinence can cause physical problems such
as skin break down and psychosocial problems
such as embarrassment and social withdrawal.
(K & E p. 1261)
Risk for impaired skin
integrity r/t bladder
incontinence and immobility.
Make sure client’s diaper is
changed so there is no build of
urine that is causative to the
client’s skin.
Provide support to the patient so
they will not be embarrassed of
their incontinence.
R.O. 8/03
3
muscle tone, enlarged prostate, surgical/
diagnostic procedures, use of foley, etc.)
 Client is immobile. =O
 Client is incontinent (bladder)= O
E
L
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M
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N
A
T
I
O
N
A
C
C
E
P
T
A
N
C
E
BOWEL:
Abdominal shape, firmness, presence of
distention and tenderness: Client’s abdomen is
not distended and is tender to touch. =O
Presence of bowel sounds: Bowel sounds were
present in all four quadrants. =O
Bowel evacuation pattern:
Date of last BM: 11/15/2007
Stool (quantity, color, odor and consistency)
Was unable to assess.
Assistive measures for bowel elimination
(laxatives, enemas, suppositories)
Other factors that may affect bowel elimination
(immobility, diet, fluid intake, meds, colostomy,
surgery, GI illness, etc.)
 Client is immobile. =O
 Client is incontinent (bowel). =O
Ability to communicate: Client only able to speak
Spanish. =O
Appropriateness of communication: Unable to
assess.
Response indicating stress: Unable to assess.
Self-concept: Unable to assess.
Significant others/support systems: Client had
numerous pictures of family and friends posted
above her bed. =O
Recent family changes/crises: Unable to assess.
Spiritual status: Unable to assess.
Cultural/ethnic influences: Client is from the
Dominican Republic. =O
Growth and development: compare client’s
psychosocial development at present with the
appropriate stage for client’s age according to
Erickson: Unable to assess.
Activity stimulates peristalsis. Immobility can
cause weak muscles and weak muscle is often
ineffective in controlling defecation. Impaired
mobility may limit the clients’ inability to
respond to the urge to defecate.
(K & E p.1229)
Risk for constipation r/t
immobility.
Assess client’s abdomen to
observe for distention.
Change client’s diaper after
defecation to keep skin integrity.
Incontinence is the loss of voluntary ability to
control fecal and gaseous discharges through
the anal sphincter. A client may experience
incontinence because of a poorly functioning
anal sphincter. (K & Ep. 1231)
Individuals with diminished ability to convey
or receive information are at risk for injury.
(K&E p671)
Monitor client’s bowel
movements in order to maintain a
pattern.
Risk for injury r/t clients
inability to communicate, as
evidenced by clients
language barrier between
client and health care
professional.
Prior to beginning any invasive
surgical procedure, confirm the
correct client, the correct
procedure, and the correct site of
the procedure using active or
passive communication
techniques.
Learn a few phrases in client’s
native tongue.
Emotional health depends on a social
environment that is free of excessive tension
and does not isolate the person from others.
Culture and social interactions also influence
how a person perceives, experiences, and copes
with health and illness. Each culture has ideas
about health. Hispanics use "hot and cold"
foods to regulate and maintain health ( K&E p.
178)
Risk for situational low self
esteem r/t physical illness,
functional impairment
(immobility) decreased
power/control over
environment aeb client being
bed ridden and unable to
communicate.
Risk for loneliness r/t social
isolation, physical isolation,
Demonstrate respect for and
accept client.
Establish therapuetic relationship
and spend time with client.
Assist the client with identifying
lonliness as a feeling and the
causes related to lonliness.
Evaluate the clients desire for
R.O. 8/03
4
aeb hospitalization and no
family interaction.
social interaction in to actual
social interaction.
Explore ways to increase the
clients support system and
participation in groups and
organizations.
Monitor and promote supportive
social contacts.
If the client is comfortable with
touch, hold the clients hand or
place a hand gently on the clients
arm.
Provide appropriate religious
materials or music.
Identify, develop, and implement
culturally appropriate spiritual
nursing interventions.
Erikson believes that life is a sequence of levels
of achievement. The greater the task
achievement, the healthier the personality of
the person. Failure to achieve these tasks is
damaging to the ego. The client is at the stage
of generatively vs. stagnation. (K&E p. 357)
and is in a state of stagnation
Delayed growth and
development r/t prescribed
dependence, separation from
significant others, effects of
physical disability aeb
listlessness, altered LOC,
lack of motor, social and
expressive skills.
Asses and identify for possible
environmental conditions, which
may be a contributing factor to
altered growth and development.
Identify coexisting health or
medical conditions that may be
contributing to to the alteration in
growth and development
R.O. 8/03
5
Delayed growth and
development r/t separation
from significant others,
effects of physical disability
as evidence by listlessness,
lack of motor, social and
expressive skills.
S
A
F
E
T
Y
Immediate Environment: Space ventilation,
lighting, temperature, noise, cleanliness: Client’s
environment was well lit, clean, and free from
clutter and well ventilated. The room temperature
was not too hot or too cold .=O
Level of consciousness: Client was awake and
alert =O
Orientation to person, place and time: Client
was oriented times 3= O
Memory (immediate recall, recent, remote):
Unable to assess.
Pupil Testing: PERRLA= O
Senses (taste, touch, smell, sight, hearing) Note
any assistive measures for sensory deficit (i.e.
Glasses, contact lenses, hearing aid): No assistive
measures for sensory deficit was seen. =O
Allergies: Unknown
People who have impaired mobility due to
paralysis, muscle weakness, and poor balance
or coordination are prone to injury. Clients with
spinal cord injury and paralysis maybe unable
to move even when they perceive discomfort.
Clients with leg casts often have poor balance
and fall easily. Clients weakened by illness or
surgery are not always fully aware of their
condition. (K&E p670-671)
Risk for impaired skin
integrity related to
immobility/incontinence/long
nails, fowlers position AEB
patient being confined to bed
and unable to move and
incontinent of urine and stool
Monitor skin color, temperature,
edema, moisture and appearance.
Turn and position client every 2
hours
Pad bony prominences to alleviate
pressure.
Keep client clean and dry of fecal
and urine and lotion skin.
Impaired skin integrity r/t
R.O. 8/03
6
Cluster all factors that place the client at risk for
physical injury (altered LOC, altered senses,
restricted mobility, age, etc.):
S
A
F
E
T
Y
S
A
F
E
T
Y
Condition of hair, mucous membrane, nails:
Client’s hair was white. Client’s mucous
membranes were pink and intact. The nail beds
were pink as well. =O
Condition of skin (describe: turgor, edema,
surgical wound, pressure ulcer, rash, drainage):
Client’s skin turgor was good. =O
Cluster all factors that place the client at risk for
altered skin integrity (immobility, incontinence,
malnutrition, dehydration, anemia, impaired
circulation, edema, diarrhea):
 Client is immobile.
 Client is incontinent bowel and bladder.
Pain (location, duration, nature, how it is
relieved): No pain was evident. =O
Temperature (oral, rectal, axillary): Oral
Temperature: 97.8 F
Cluster all factors that place the client at risk for
biological injury (altered skin integrity,
decreased WBC, IV, foley, surgery, other
invasive procedures, malnutrition, cancer, AIDS,
chemotherapy, etc.):
 Client has tracheotomy.
Lab results: WBC:
Reports:
(norm =
), Culture
Moisture from incontinence makes the
epidermis more easily eroded and susceptible
to injury. Digestive enzymes in feces also
contribute to skin excoriation. Any
accumulation of secretions or excretions is
irritating to the skin, harbors microorganisms,
and makes the individual prone to skin
breakdown and infection. (K&E p858)
immobility, resting in the
Fowlers position.
Minimize exposure of skin
impairment and other areas to
moisture from incontinence,
perspiration or wound drainage.
Do not position client on site of
skin impairment.
Select a topical treatment that will
maintain a moist wound healing
environment and that is balanced
with the need to absorb exudate.
Evaluate for use of speciality
matresses, beds or devices as
appropriate.
Maintain the head of the bed at the
lowest possible degree of
evaluation to reduce shear and
friction forces.
Nosocomial infections are common in hospital
surgical and intensive care units. The urinary
and respiratory tracts and the bloodstream and
wounds are the most common sites of infection.
(p.631)
Risk for infection related to
invasive devices AEB
tracheotomy.
Wash hands before and after each
patient care activity.
Ensure aseptic handling of all
surgical sites and invasive devices.
Other lab results: PT:
(norm = ), PTT:
(norm =
), INR: (norm = )
Fluid and electrolyte balance:
Lab results: Na: 139 (norm= 135-143), K: 3.7
(norm = 3.5-5.3), CL: 109 (norm = 95-111), Ca:
(norm =
), BUN: 12 (norm = 5-25 ),
Creatinine: 0.6 (norm = 0.5-1.4 )
I & O for two previous daysDate:
Intake:
IV:
PO:
;
Output: Urine:
Other:
;
Date:
Intake: IV
PO
;
Output: Urine:
Other:
Unable to assess as client is incontinent bladder. =O
.
R.O. 8/03
7
IV fluid (type, amount, solutions added, rate
cc/hr., gtts/min):
Cluster all signs and symptoms of FVE or FVD
(skin turgor, I&O lab data, mucous membrane,
weight, urine, vital signs, edema, ascitis, etc.):
Cluster all factors that place the client at risk for
fluid and electrolyte imbalance (surgery, NPO,
decreased food and fluid intake, diuretics, IV, GI
drainage or suction, abnormal I&O CHF, renal
impairment, liver disease, diabetes, etc.):
O
X
Y
G
E
N
A
T
I
O
N
Alcohol and/or unprescribed drug use:
Prescribed medication: action, purpose, side
effects (attach drug cards):
Skin: warmth and color (include lips, nail beds,
lower extremities): Skin was dry and cool to
touch. Lips and nail beds were pink. = O
Capillary refill: upper extremities less than 2
seconds, lower extremities less than 2 seconds
V/S: B/P: lying down 125/ 54, sitting
, pulse
pressure
Pulse: rate 67/ min , rhythm good rhythm
quality strong
Apical/radial pulse: apical
, radial
,
pulse deficit
Indicate + or - : brachial R
,L
;
femoral R
,L
; popliteal R
,L
; posterior tibial R
,L
; dorsalis pedis R
,L
Quality of pulses on lower extremities:
Assistive measure for circulation (anti-embolic
stockings, sequential compression device):
Cluster all factors that may effect the
cardiovascular system (immobility, CHF, DM,
PVD, thrombosis, HTN, surgery, anemia, etc.):
Immobility affects the respiratory system by
causing decreased respiratory movement,
pooling of respiratory secretions, atelectasis
and hypostatic pneumonia. (K&Ep1069)
Care for the client with a tracheotomy reduces
the risk for infection. (K&Ep. 1315)
The Fowlers position may result in shearing
forces on the skin, especially in the sacral area.
Normal breathing is silent but many sounds
occur when there is the presence of fluid in the
lungs. (K&Ep. 506)
Breathing pattern ineffective
r/t artificial airway,
immobility aeb adventitious
breath sounds bubbling
sound and presence of
secretions resting in the
fowlers position and using 2
pillows.
Airway clearance ineffective
r/t presence of artificial
airway, smoking, retained
secretions aeb dyspnea and
adventitious breath sounds.
Monitor for symptoms of heart
failure and decreased cardiac
output.
Note results of EKG and chest
radiograph Administer oxygen as
needed
Monitor oxygen saturation and
blood gas
Position the client in the semi
fowlers position
Provide suctioning as needed
O
X
Y
G
Respiration rate 18/ min, rhythm good rhythm,
depth labored breathing. =O
Smoking (never, smokes presently, amount, for
how many years, used to smoke, when stopped):
Unable to assess
Estimate of activity intolerance: presence of
dyspnea at rest and/or with exertion, pulse rate:
Breath sounds, presence of cough, presence of
secretions (describe):
Position the client to optimize
respiration.
Clear secretions by suctioning as
necessary.
Use a closed in line suction
system.
R.O. 8/03
8
E
N
A
T
I
O
N
Position for sleep (number of pillows, Fowlers’
or semi Fowlers’ position): 2 pillows; SemiFowlers Position. =O
Assistive measures for respiration (02, coughing
and deep breathing exercises, suction, incentive
spirometer, chest physiotherapy, etc.): Client has
tracheotomy. =O
Hyperoxygenate before and
between endo tracheal suctioning.
Lab results:
Lab RBC
(norm = ), HGB
(norm = ), HCT
(norm =
)
ABG: pH
(norm = ), PCO2
(norm =
), PO2
(norm =
), HCO3
( norm =
),
O2 saturation
(norm =
)
Other factors that may affect the respiratory
system (immobility, pleural effusion, lung
cancer, COPD, asthma, etc…):
N
U
T
R
I
T
I
O
N
Height: 5’ 2 ; Weight: 183 , BMI: 33
Normal weight range for this client (according to
age and height): 128lbs-143lbs
General Appearance (muscular, obese, normal
weight, underweight, emaciated): Client is over
weight. =O
Condition of teeth/gums/tongue: Gums and
tongue are pink. =O
Ability to swallow: Client able to swallow. =O
Diet prescribed: Soft mechanical chew. =O
Describe appetite, percentage of food and fluid
intake: Client drank 2 four fluid ounce cartons of
milk; and 1 eight fluid ounce can of ensure. = O
Previous eating patterns: Unable to assess.
Assistive measures for nutrition: tube feeding,
adaptive silverware, hyperalimentation:
When a person is immobile, the muscles of the
body are not being used. Unused muscles
atrophy (decrease in size). As a result, the body
may not require as much protein and other
nutrients, causing an imbalance in nutrition as
excess nutrients are eliminated and not used.
(K&E, 1068, 1173)
The normal daily liquid and calorie
requirements for adults age 18 and up are 22002700 mL and 2000-2500 calories. (K&E, 1356)
Obtaining clients previous eating patterns
provides information about what types of foods
are eaten and the frequency and amount. The
nurse can then predict which foods are in
Imbalanced nutrition: more
than body requirements r/t
immobility aeb low muscle
mass.
Monitor clients protein intake.
Provide an adequate amount of
protein according to activity level.
Provide an adequate amount of
daily ROM exercises to make use
of energy and nutrients.
Ensure that the client receives
his/her daily feedings on a regular
schedule.
Place client in a low Fowler's
position to prevent aspiration.
R.O. 8/03
9
N
U
T
R
I
T
I
O
N
Health conditions that may affect nutrition
(cancer, chemotherapy, GI and liver disease,
diabetes, anorexia, n+v, diarrhea, altered LOC,
etc.):
Other factors that may affect nutrition:
knowledge deficit, culture, religion, economic
status, lifestyle, psychological factors, alcohol
and drugs):
Lab results:
Serum albumin:
(norm =
), Blood
glucose:
(norm =
);
Lipid profile: HDL
(norm =
), LDL
(norm =
), Total Cholesterol
(norm =
), triglycerides
(norm = )
Urine glucose:
norm =
), Urine
acetone:
(norm =
)
Cluster all clinical signs of malnutrition: altered
lab, skin and hair condition, activity tolerance,
weight, mucus membranes, GI, vitality,
neurologic, etc.):


excess or deficient, which may predispose the
client to imbalanced nutrition. (K&E, 1193,
1196)
Client is immobile. =O
Client is over weight. =O
R.O. 8/03