Case Study #1
Nsg Dx: Nutritional imbalance, less than body requirements r/t nausea and diarrhea AEB pt reports of
“light-headedness” and daughter’s report that she has had nothing to drink in 2 days.
Goal:
The pt’s nausea and Diarrhea will improve in 36 hrs AEB:
 denies having light-headedness

Has soft, formed BM, pt’s GI elimination pattern returns to “normal”: for her.

Skin turgor WNL

Fluid intake up to 1000 ml/day.
Well done. The goal is directed at the etiology (and the problem statement. You have an intro with time frame and 3 measurable outcome criteria. Well done! I suggested another way you could word one of your outcomes – but yours would have been acceptable.
Case Study #1 – 2 nd
group
Nsg Dx: Nutritional imbalance, less than body requirements r/t nausea and diarrhea AEB pt reports of
“light-headedness” and daughter’s report that she has had nothing to drink in 2 days.
Goal: Improve nausea and diarrhea AEB:

Improved skin turgor

Increased intake by 50%

Soft, formed stool
Good job! Editorial work with the intro – most goals will start with “The pt…” or “the client…” Note that your intro did not have a time frame – I will add one. Improved Skin turgor – note that pretty much skin turgor is WNL or it is not. I suggested another way to state the last outcome criteria – but yours would have been fine.
The pt’s nausea and diarrhea will improve in 24 hours AEB:

Improved skin turgor
(let’s change this to Skin turgor WNL – that would be more clearly measurable)

Increased intake by 50%

Soft, formed stool ( pt’s GI elimination pattern returns to “normal”: for her)
Case Study #3:
Nsg dx: Pain, acute r/t constipation AEB reports no BM in 2 days, abdomen distended and tight.
Goal: The pt’s GI elimination patterns will be improved in 48 hours AEB:

Soft formed BM ( pt’s GI elimination pattern returns to “normal”: for her)

Abdomen soft and nondistended

Pt denies pain 2 nd
to abdominal distention.
Well done – I suggested another way to state one of your outcomes – but the one you had would have been fine.
Goal #2: the pt’s anxiety level will improve within 24 hours AEB:
 Pt’s knowledge of medication will increase ( see my comments below re: this outcome)

Pt accepts pain medication at designated time
 Pain score decreases to “2” on a scale of “1-10”.
Another good goal. Great intro with time frame. I like your outcome criteria, too. Note that you need to address how you will know how “the pt’s knowledge of medication has increased” – how would you know this? How do we know when our teaching is effective – what change would you see in the pt’s behavior.
There are several ways to say this – one would be “Pt verbalizes rationale for medication” or “Pt verbalizes understanding that medication would only be addictive if taken repetitively over a prolonged period of time”.
Case Study #4:
Nsg dx: Sleep deprivation r/t anxiety AEB verbalization of lack of sleep and caffeine intake.
Goal: Pt’s anxiety level will decrease as a result of decreased caffeine intake and adequate amt of sleep in
48-72hrs AEB:


3-4 diet cokes/day

2-3 cups coffee/morning

6-8 hrs sleep/night.
You have developed an intro with a time frame (good!) and you have 3 very clear outcomes listed
(Excellent!). Although your intro is OK – another wording could be:” The pt will use methods to decrease her anxiety level in….”
Case Study #5:
Nsg dx: Surgical recovery delayed (risk of) r/t pt’s refusal to follow postop regime AEB pt’s refusal to sit up or cough and his fear that “incision will burst open”.
Goal: The pt will dangle on the side of the bed at 90 degree angle in 24 hours AEB:
 decreased fear regarding incision
Nicely done…..You have the correct components – but they are in the wrong place. How will you measure
“decreased fear...”? Remember that the outcome criteria need to be measurable. Let’s rearrange – using what you have developed:
The pt will have decreased fear regarding incision in 24 hours AEB:

Pt dangles on the side of the bed at 90 degree angle.
Goal #2: The pt will cough and deep breathe q2hrs AEB:

Increase in respiratory excursion.
I LOVE your use of respiratory excursion!!! Again you have an outcome criteria as your intro…Let’s reword your intro:
The pt will cough and deep breath effectively every 2 hrs in 24 hours (I added a time frame) AEB:

Increase in respiratory excursion.
Case Study #6:
Nsg dx: Risk for infection transmission r/t daughter not using appro isolation precautions.
Goal: The pt’s daughter’s knowledge of isolation precautions will improve by next visit AEB:

Daughter uses appro isolation precautions 100% of the time.
 The Daughter will verbalize steps and risks associated with isolation before entering the pt’s room.
Excellent….You have an intro with time frame and 2 measurable outcome criteria. Good job!
Case Study #7:
Nsg dx: Impaired verbal communication r/t review of discharge instructions in English AEB shaking his head, verbalizes “no comprende”.
Goal: The pt will comprehend discharge instructions before going home AEB:

Pt nods his head and verbalizes “comprende”,

Translator states that pt has verbalized understanding of discharge instructions

Pt begins preparing to go home.
Well done – good job with intro with a time and 3 measurable outcome criteria.
Case Study #8:
Nsg dx: Nutrition imbalance: more than body requirements r/t excessive sugar intake AEB 24 hr recall that reveals desserts after every meal.
Goal: The pt’s BG will decrease in 48 hrs AEB:

Normal accucheck BG,
 Pt’ comprehension of RDA diet guidelines.
(How will you measure this? How will you know that the pt comprehends?)
Well done. You have the correct components (intro with timeframe and 2 outcome criteria). You do have outcome criteria in the intro – I would suggest moving this to the outcomes and rewording the intro…
The pt will understand how to modify her diet to maintain optimal BG levels in 48 hrs AEB:

Accucheck values are WNL

Pt verbalizes the RDA diet guidelines for her prescribed diet correctly.

Case Study #8 – group 2:
Nsg dx: : Nutrition imbalance: more than body requirements r/t excessive sugar intake AEB 24 hr recall that reveals desserts after every meal.
Goal: Pt will consume well balanced diet w/o excessive sweet intake. Pt will have understanding.

Pt states better understanding of rationale and states compliance,

Pt consumes 100% of dietary tray w/out excessive “dessert” consumption.

BG is w/in normal range consistently.
Nice start. Your intro has appro components. I’ll suggest some editorial revisions. Need to add a time frame for completion/accomplishing the goal. The outcome criteria are good – I made some editorial suggestions…
The pt will have an understanding of how to consume a well balanced diet w/o excessive sweet intake in 24 hours AEB:

Pt correctly states rationale for well balance diet w/out excessive sweet intake

Pt verbalizes desire to comply with prescribed diet

Pt consumes 100% of dietary tray, pt does not consumer supplemental high CHO dessert

BG with WNL consistently.
Case Study #9:
Nsg Dx: Anxiety r/t admission to hospital AEB verbalization of “I’m scared of hospitals” and resp. rate of
45/min.
Goal: Pt will be calm with decreased anxiety within one hour AEB:

Decr. Resp. rate WNL (Resp. rate WNL)

Pt appears to be calm (How will you know he is calm? List the indicators you will use to determine he is calm: relaxed facial expression, resting quietly in bed, denies anxiety…)

Other v/s WNL

Pt verbalizes comfort.
Good job – I have made some editorial suggestions. You only need to address how you will measure appearing “calm”.
Case Study #10:
Nsg dx: Disturbed visual perception r/t forgetting his glasses AEB pt verbalization of “I’m blind without my glasses”.
Goal: The pt’s vision will be optimal in 24 hrs AEB:

Pt will have access to glasses to wear as needed

Pt wearing his glasses.
Well done – You have addressed each part of the goal appro.
Case Study #19:
Nsg dx: Alt. in comfort r/t absence of BM times one week AEB distended abdomen.
Goal: The pt’s elimination pattern will be improved in 24 hours AEB:

Incr. in fluid intake ( give your ideal)

Soft, formed BM
(or return to pt’s normal gi elimination pattern)

Pt denies pain secondary to abd. Distention

Incr. in fiber intake . (give your ideal – or just state that she includes food with fiber in her diet each day)>
Well done – you included appro components in each area. I only made editorial suggestions.