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NURR 100 LEARNING MODULES
Nursing Process – Overview Learning Module 1
Purpose
This learning module is the first of a series on nursing process. This
learning module provides a broad overview of the nursing process.
Objective


Learning
Activities
1. First review Potter, chapter 15, and the lecturette below.
2. Complete the "A Busy Day" assignment included in this
learning module. Correlate the nursing activities listed in the
document with the various steps of the nursing process. Note
some may include more than one step.
3. Discuss this on Blackboard Discussion Board by the due date.
Describe the phases of the nursing process.
Discuss the steps that constitute nursing assessment
The nursing process represents a way of thinking. It is a framework nurses use to
organize thinking about clients. The nursing process is a problem solving process.
Potter (2009) provides rationale in chapter 15 for using the nursing process as an
organizing framework for nursing practice. Central to the discussion is the definition of
nursing. The 5 phases of the nursing process:
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



Assessment
Diagnosis
Planning
Implementation
Evaluation
Potter (2009) describes each of the phases in the nursing process that serve to guide
nursing activity. The following learning modules in this series discuss each phase in
detail.
The phases of nursing process do not occur in isolation. They are cyclical and the nurse
may move from one phase to another in varying order. As Potter emphasizes, the most
important aspect is to think critically when providing care.
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A Very Busy Day
Time
Event
1925
1930
1940
1945
Completed report for 3 post op patient
Made quick rounds to check on patients
Finished reorganizing “brains”
C.N.A. reported that the spider bite pt's IV was swollen and the
urethral shunt post op pt's Temp was 104.2.
Checked on the patient with the spider bite to assess the IV site,
turned off the IV fluids, dc'd the IV and placed a warm washrag on
the IV site.
Checked on the patient with the urethral shunt, repeated the temp 104.6. Placed cool washrags on her neck and in her armpits.
Looked through MDs orders for antipyretics, none ordered, placed
a call to the MD
Checked on patient, new vaginal hysterectomy, wrote name/title
on her dry erase board
Received order for Tylenol and alcohol sponge bath
Explained the MD’s orders and rationale to the family and patient.
Answered questions about the procedure. Medicated the pt with 2
Tylenol 325mg tabs.
Retrieve supplies for alcohol bath. Stopped to check on the patient
with the spider bite to check the IV site and let her know that I
would be back in 30 minutes to re-start her IV and start 2200 dose
of Vancomycin
Started alcohol sponge bath when MD called back again. T.O. to
change Unasyn from 1.5g to 3.0g Q8hrs, starting at 2200 dose.
Completed sponge bath. Restarted IV on patient with spider bite
and hung Vancomycin
Started Unasyn IVPB. Completed assessment while infusing,
explained cough, deep breathe and turning as well as increased
fluid intake to assist in keeping her temperature down. Tympanic
temp 101.8.
Checked on patient with vaginal hysterectomy. Stated the pain
4/10. Administered 2 Lortab 7.5mg and assisted her back to bed.
Checked on Vancomycin IVPB – complete and maintenance
fluids are infusing.
MD calls again regarding patient with urethral shunt – gave
update. Checked on patient – asleep and family gone.
Hung new bag LR D5W on patient with spider bite.
Started dressing change on patient with spider bite.
1. Removed and discarded old dressing.
2. Placed 4X4's that are soaked in sterile water over the
wound.
3. Covered with gauze.
4. Wrapped in cellophane.
5. Wrapped K pad around the dressing.
Gave the patient her PCA controller and made her comfortable.
Patient went to sleep immediately.
1947
2004
2030
2040
2055
2005
2115
2120
2155
2220
2300
2310
2325
2345
2400
Steps of Nursing
process
3
Time
Event
0100
Completed documentation of assessments, I/O forms, and new
shift documentation.
Woke up patient with urethral shunt after C.N.A. reported that her
temperature was 102.3. TCDB, ambulated to the bathroom, drank
260cc's water, and use incentive spirometer. Administered 2 tabs
Tylenol 325mg tabs.
Patient with urethral shunt temp was 100.7 tymp. Made rounds on
other 2 pts, both sleeping but easily aroused.
Lab tech in to draw CBC on patient with spider bite.
Hung new bag of LR on patient with urethral shunt.
0215
0245
0400
0420
Steps of Nursing
process
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Nursing Process – Assessment: Module #2
This learning module focuses on assessment – the first step in the
nursing process.
Purpose
Objectives




Learning
Activities
Identify the purpose of nursing assessment.
Discuss the steps that constitute nursing assessment
Describe types of assessment data (i.e., subjective and
objective data).
Use Gordon's Functional Health Patterns to organize
assessment data.
1. First review Potter (2009), Chapter 16, and read below.
2. Look at the "Case Study" posted at the beginning of this
learning module. Using the case study identify:
a. The patterns in Gordon's Functional Health Patterns
that apply specifically to the case study.
b. Label the data as either subjective or objective for
each of the patterns identified.
3. Discuss this on Blackboard Discussion Board by the assigned
date.
Assessment is the first phase of the nursing process. During assessment a
database is developed. It is essential to develop a sound and thorough database.
The diagnoses you write and the actions you implement will be only as good as
the data base.
Data collected includes both subjective and objective data. Data may be
gathered from many sources; however, data collected directly from the client
and those associated with his or her care are most helpful. One of the most
frequently used formats for organizing assessment data has been developed by
Marjorie Gordon. A brief outline of Gordon's Functional Health Assessment
follows:
Pattern #1: Health Perception/Health Management
Describes the client's perception and management of health and well-being. Adherence to preventive
health practices.
Subjective Data:
Reason for admission, prescription and non-prescription medications (including
illicit drug use), medical-social history, expectation of health care providers,
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ongoing treatment unrelated to admission diagnosis, client's perception of health
status and well-being.
Objective Data:
Age, hygiene, grooming.
Pattern #2: Nutrition-Metabolic
Patterns of food and fluid intake, fluid and electrolyte balance, general ability to heal.
Subjective Data:
Usual diet (e.g., 24-hour recall of a typical day's diet); allergies to food, appetite,
caffeine use, problems with eating, swallowing, digesting; nausea; routine hygiene,
ability to heal
Objective Data:
Prescribed diet, percent of food taken, ability to swallow, nasogastric tube,
parenteral fluids, intake/output
Temperature, height, weight, condition of teeth or dentures
Skin assessment – note especially any points of skin breakdown
Related laboratory data
Pattern #3: Elimination
Describes patterns of excretory function of the bowel, bladder and skin.
Subjective Data:
Usual bowel habits (i.e., frequency of bowel movements, use of laxatives, problems
with constipation or diarrhea, use of stool softeners)
Usual bladder habits (i.e., how often the individual urinates, problems with starting
or stopping urinary stream, completeness of emptying bladder, leaking)
Objective Data:
Bowel movements – Stool amount, color and consistency
Urinary output – color, amount, presence of catheter(s)
Abdominal assessment
Related laboratory data
Diaphoresis, body odor, drainage tubes
Pattern #4: Activity Exercise
Describes patterns of exercise and activity, respiratory and circulatory function.
Subjective Data:
Ability to perform activities of daily living – bathing, feeding, toileting, dressing,
meal preparation, light housekeeping, shopping
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Objective Data:
Cardiac assessment
Respiratory assessment
Mobility – gait problems, stair climbing, use of cane or walker
Related laboratory data
Pattern #6: Cognitive-Perceptual
Describes patterns of hearing, vision, taste, touch, smell, pain perception, language, memory and
decision-making.
Subjective Data:
Sensory and perceptual problems related to hearing, vision, touch, taste, smell
English as second language, educational level
Pain perception using pain rating scale of 1-10, 10 being extreme pain (COLDAR)
and pain management pain
Memory changes
Objective Data:
Orientation to person, place, time
Awareness of body parts
Aids such as glasses, hearing-aides, Neurologic examine
Related laboratory data
Pattern #6: Sleep/Rest
Describes patterns of sleep, rest and perception of energy level.
Subjective Data:
Usual bedtime routine and hours of sleep, awakenings and reasons for awakening,
statement of energy levels for daily activities, complaints of drowsiness or fatigue
Objective Data:
Irritability, disorientation, frequent yawning, slurred speech
Pattern #7: Self-perception/Self-concept
Describes attitudes about self and perception of abilities.
Subjective Data:
Attitudes about self, impact of illness on self, desire to change self, nervous or
relaxed rate on scale 1-5, perceived powerlessness.
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Objective Data:
Body posture, eye contact, facial expressions, diagnostic studies
(Remember, you must consider the individual's cultural heritage when making
judgments about self-perception/self concept issues.)
Pattern #8: Role/Relationship
Describes effectiveness of roles and relationships with significant others.
Subjective Data:
Effectiveness of relationships with significant others, effect of role change on
relationships – availability and ability of support system
Employment, financial concerns, residence
Objective Data:
Observed interactions such as passive or aggressive behavior toward others
Pattern #9: Sexuality/Reproductive
Describes actual or perceived satisfaction or problems with sexuality. Reproductive stage and pattern.
Subjective Data:
Impact of illness on sexuality
Menstrual history; self-breast exam or testicular exam, birth control measures
History of sexually transmitted disease
Objective Data:
Breast, testicular, genital exams
Related laboratory data
Pattern #10: Coping/Stress Tolerance
Describes ability to manage stress and use of support systems.
Subjective Data:
Stressors in the past year, usual coping methods, support system, use of alcohol,
illicit and/or prescription drugs to alleviate stress, effect of illness on stress level,
anxiety level rated on scale 0-5, 5 being extreme anxiety
Objective Data:
Observed interactions with significant others, kinetic movements, pacing, voice
tones
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Pattern #11: Value/Belief
Describes spirituality, values, and belief system.
Subjective Data:
Religious, cultural beliefs and practices
Statements of significant persons (e.g., might be individuals or pets)/activities/events
that provide a lynchpin for living
Attitude toward do not resuscitate (DNR), living will and durable power of attorney.
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GORDON’S FUNCTIONAL HEALTH PATTERNS
STUDENT ASSESSMENT GUIDE
#1
#2
#3
#4
HEALTH MAINTENANCE MANAGEMENT
Admit date
Medical Diagnosis
Pertinent medical history
Pertinent psychosocial history
Insurance/Financial concerns
Age
Allergies/Food and Medicine
Erikson’s Developmental Level*
Tendency toward which pole*
Perception of health status
Immunization status
Risk behaviors
Discharge needs
Medications prior to admission
NUTRITION/METABOLIC
Diet
Recent intake (% of meals)
Food Preferences*
Abdomen
Bowel sounds
Nausea
NG tube*
IV Fluids*
Intake/Output (# of hours)
Temperature
Edema
Height and Weight
Body mass index*
Health risk related to score*
ELIMINATION
Bladder
Bowel patterns
Last bowel movement
Skin
Wound/Incision/Drain
Braden scale score*
Risk related to score*
Wound incision
Wound drainage system
ACTIVITY/EXERCISE
Respiratory-Rate
Character of respirations/Cough
Color (related to oxygenation)
Breath sounds
SpO2*
Cardiac-Apical pulse rate, rhythm, and sounds
Peripheral pulses*
Capillary refill time*
Blood pressure
Range of motion
SUBJECTIVE
OBJECTIVE
10
#5
#6
#7
#8
#9
#10
#11
Mobility (describe extent)
Assistive equipment
ADL performance
Leisure and recreation
COGNITIVE/PERCEPTUAL
Pain (scale, characteristics)
Glascow score*
Sensory aids
Level of consciousness
Circulation, Motion, Sensation (CMS)
SLEEP/REST
Pattern of Sleep
Quality/Quantity
SELF-PERCEPTION/SELF ESTEEM
Describes attitudes about self and perception of abilities*
Impact of illness of self*
Desire to change self*
Nervous or relaxed: supportive data
Perceived powerlessness
Body posture*
Eye contact*
Assertive or passive: supportive data
Nonverbal cues to self-esteem*
Facial expressions*
ROLE/RELATIONSHIPS
Occupation
Recent change in role
Comfort with change
Marital status
Family structure
SEXUALITY
Menstrual history: children
Self-breast/testicular exams
Impact of illness on sexuality
Birth control
Prostate specific antigen
COPING/STRESS
Expression of stress
Stressors
Usual coping mechanisms
Support systems
Family support
Community resources
VALUE/BELIEF
Religious preference
Spirituality
Cultural beliefs and practices
Practice of values/beliefs
Advance directives
DNR
*All starred items require either a subjective or objective information, all other areas
require both subjective and objective data to be included.
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Nursing Process – Diagnosis: Learning Module #3
Purpose
Objectives
This learning module focuses on diagnosis: the second step in the
nursing process. In this step of the nursing process judgments are
made about the assessment data and nursing diagnosis are formulated.






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Learning
Activities
Describe the process for deriving diagnostic statements.
Differentiate between nursing diagnoses and a medical
diagnosis.
Identify the steps of the nursing diagnosis process.
Explore the relationship of defining characteristics to
assessment cue.
Explain what makes a nursing diagnosis correct.
Differentiate between nursing diagnosis and collaborative
problems.
Develop nursing diagnosis statements.
1. First review Potter (2009), Chapter 17, and read below.
2. For ER, the client in the case study that you used in the last
learning module, develop
a. Two actual nursing diagnoses
b. One risk (potential) nursing diagnosis
3. Discuss on Blackboard Discussion Board by the due date.
Developing Diagnostic Statements
The diagnostic phase of the nursing process starts with analysis and includes an
evaluation about the client's health status. Diagnoses are derived from the assessment data
you collected. You must begin by:
1. Sorting through all of the data you have
2. Identifying problem areas
3. Clustering the data from problem areas
For example, suppose your assessment includes the following data:
Elimination: Usual bowel pattern – every morning, complains of constipation, hard "pebbly"
stools
Cognitive-Perceptual: Complains of bone pain, R lower-leg, rates the pain as 7 on 1-10 scale,
10 being extreme pain; Manages pain with Vicodin, tabs 2, prn.
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4. The data indicates two problems exist. However, the constipation is likely related
to the Vicodin. Consequently, the data are clustered together.
5. Comparing the data to norms
6. Evaluating what it means
After you complete this process, you will develop a diagnostic statement. A diagnostic
statement represents a label that describes your clinical judgment about the client.
Diagnoses are validated with the client, family, and other health care providers.
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Developing Nursing DiagnosesThere are three types of nursing diagnostic statements. Remember, we are dealing with
diagnoses that nurses can independently treat.
1. Actual Nursing Diagnoses – diagnoses that the client has RIGHT now.
To write an actual nursing diagnosis, you will write a 3-part statement:
Problem (label/diagnostic statement) — Etiology (cause) — Clinical
Manifestations
For example:
Activity Intolerance r/t leg pain AEB pain of 5/10 in right leg with ambulation.
"Activity intolerance" is the label, "leg pain" is the etiology and "pain 5/10" is the
symptom. Because it is an actual diagnostic statement (present right now), all 3
parts are present. The signs or symptoms that are used are the symptoms that the
client is actually exhibiting.
Note the use of the abbreviation of (r/t) for related to and (AEB) for as evidenced
by. Feel free to abbreviate those terms and save yourself some writing!
2. At Risk Nursing Diagnoses – diagnoses for which the client is at risk but do not
actually exist right now. There is the possibility that if nothing is done an actual
nursing problem may occur.
To write a 'risk' diagnosis, the client must be at greater risk for this problem than
someone else in the same situation. For example all post-operative clients are at
risk for infection, but it would be inappropriate to write that problem statement for
all operative clients. However, if the client has a depressed immune system, a risk
diagnosis would be very appropriate.
Risk diagnoses consist of 2 parts:
Problem (label/diagnostic statement) — Etiology (cause)
There are no symptoms because the problem does not actually exist at this time.
What you will have are risk factors.
For example:
Risk for activity intolerance r/t leg pain
This would be appropriate for a client who was having increasing pain and was
beginning to curtail activities as a result of the pain. No symptoms are listed
because they are not actually present. Risk factors might be limited movement,
sleeping for 15 hours per day, and pain of 7 out of 1-10 pain scale.
3. Wellness Diagnoses – diagnoses are used for clients who are functioning
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adequately at the present time. However, they have a desire to improve their level
of functioning. For example, they might want to eat better or lose weight.
You would NOT use this diagnosis if YOU want the client to change. It is only
appropriate if the client expresses the desire to change.
A wellness diagnosis is a 1 part statement. The diagnostic statement begins with
the statement Potential for enhanced . . .
For example: Potential for enhanced nutritional status.
Remember that the client has to be functioning effectively in order to be a
wellness diagnosis. If the client is not functioning effectively, a problem exists.
Note that NANDA-approved nursing diagnoses (see Ham, 2002, Box 7-1, pages 134-136) are used for the
Problem (label/diagnostic statement).
To identify the appropriate Problem (label/diagnostic statement) for a client, use reference books such as:
Carpenito, L.J. (2000). Nursing diagnosis: Application to clinical practice (8th ed.). Philadelphia:
Lippincott.
Doenges, M.E., Moorhouse, M.F., Geissler, A. C. (2000). Nursing care plans (5th ed.).
Philadelphia: F. A. Davis.


SN Student Nurse
http://studentnurse.hypermart.net/carepla ns .htm
RN Central – click on "Care Plans"
http://www.rncentral.com
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Developing Collaborative Problems
A Nursing Diagnosis reflects the client's response to a disease or pathological process.
The Nursing diagnosis allows the nurse to identify those client responses and client
problems that are the responsibility of the nurse. These nursing diagnoses are then the
basis for the planning, implementing, and evaluating the nursing care plan and the client's
health status.
On the other hand, medical diagnoses are physiologic aberrations that require medical
interventions. Nurses do NOT make medical diagnoses. Making a medical diagnosis is
outside nursing's scope of practice (please refer to Idaho's Nursing Practice Act available
on-line at www2.state.id.us/ibn/ibnhome.htm). Rather, nurses work collaboratively with
physicians in a mutual effort to avoid further complications or changes in status of the
complications related to the physiologic aberration. Nurses make collaborative diagnoses
to provide focus for this collaborative effort. Please read carefully the description of
collaborative problems in Potter (2009), page 248.
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Nursing Process – Planning: Learning Module #4
Purpose
Objectives
This learning module focuses on planning – the third step in the
nursing process. In this step of the nursing process the care is
individualized to meet the client's needs.





Learning
Activities
State the three components of the planning process of the
nursing process.
Prioritize client problems using Maslow's Hierarchy of
Human Needs.
Develop SMMART outcome statements or goals for nursing
diagnostic statements.
Develop nursing outcomes or goals for collaborative
diagnostic statements.
Write nursing interventions for both nursing and collaborative
diagnostic statements.
1. First review Potter (2009), Chapter 18-- and read the lecturette
below.
2. For ER, the client in the case study that you have been using,
a. Prioritize the diagnostic statements according to
Maslow's Hierarchy of Human Needs. State your
rationale.
b. Prepare SMMART outcome statements for each of the
diagnostic statements.
c. Write three nursing interventions for each of the
diagnostic statements.
3. Discuss on Blackboard Discussion Board by the assigned
date.
Planning a client's care actually consists of three parts:



Setting priorities
Setting goals/outcomes
Planning interventions/actions
Setting Priorities
The planning phase involves setting priorities. Several of the questions that must be
addressed when setting priorities include: Which of the client's diagnostic statements
represents the priority? Which should be addressed first? Which ones can the nurse deal
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with and which should/could be delegated to a different level of provider?
In 1970, Maslow developed a hierarchy of human needs. This hierarchy can be used as a
guide to determine priorities for care. Maslow's hierarchy of human needs is frequently
depicted on a triangle with the most basic (and important) human need at the bottom of
the triangle.
1.
2.
3.
4.
5.
The most basic level includes physiologic
needs (air, water, and food).
The next level includes safety and security
needs. This includes both physical and
psychological needs.
The third level is love and belonging. This
includes friendship, social relationships, and
sexual needs.
The fourth level is self-esteem. This includes
self-confidence, usefulness, achievement, and
self-worth.
The top level is self-actualization. This is the
state of fully achieving potential.
According to this theory, people cannot deal with higher level needs until their basic
needs are met. Maslow's hierarchy is a useful guide to use in determining priorities. Be
sure to always consider what the client considers the most important problem!
Setting Goals
Another important part of planning is setting goals/outcomes. Goals/outcomes are derived
from the diagnoses. Goals/outcomes must be set in conjunction with the client.
Goals/outcomes that are set FOR the client not WITH the client, do not work.
Writing outcome statements or goals for Nursing Diagnoses. Guidelines include:

Write goals or outcomes that are SMMART.
o Specific: Be very clear about exactly what should happen.
o Measurable: Must be able to be seen, heard, etc and judged in some way.
o Mutually Set: The client has been involved in discussion and agreed to
the outcome.
o Achievable: The client has to be able to attain the goal. If the client
couldn't walk before his hernia operation, chances are he won't walk after
the hernia operation.
o Reasonable: The goal should be in line with what the client is capable of
achieving.
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o
Timed: Set a date (time frame) to evaluate the goal.
So — for an outcome for a NURSING DIAGNOSTIC statement, check to make
sure it is SMMART.

Use verbs that are measurable.
For example, after discussion with the client the nursing diagnostic statement
reads: The client will correctly demonstrate wound care by discharge. This is an
example of a SMMART outcome statement. As that client's nurse, I know that
before it is time to discharge the client, I need to be sure he/she has been taught
and can do wound care. Measurable terms include: states, performs, identifies, or
reports.
Another example: The client will understand how to do wound care by discharge.
This outcome statement is NOT measurable. How do you know whether the client
understands? Non-measurable terms include: accepts, knows, appreciates, or
understands. Using terms such as these are not acceptable. They must be
measurable.
Writing outcome statements or goals for collaborative problems. When writing
outcome statements for collaborative problems you do not need to worry about
SMMART. For collaborative problems, the goal or outcome statement is a function of
what the nurse will do. These are written: The nurse will monitor, manage, and minimize
the effects of . . . (whatever the PC is).
For example,
The nurse will monitor, manage and minimize the symptoms of the client's small bowel
obstruction and keep the physician notified of any complications or worsening of the
client's condition.
Planning Interventions
Nursing interventions/actions/orders must be developed and carried out.
Procedures/protocols, standards of care, textbooks, and articles are all good sources of
possible interventions. Those general interventions, however, must be tailored for the
particular client and his/her needs.
Each intervention should be aimed at helping the client reach the outcome/goal that was
written. Interventions tend to deal with the cause (etiology or related to factors) of the
problem. If the cause of the problem can be dealt with correctly, the problem will be
lessened and the goal/outcome attained.
Interventions have some things in common whether they are written for nursing diagnoses
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or collaborative problems (PCs).



They must be written specifically enough that they can be followed. For example,
"Increase fluids" really does not mean anything. Be specific. For example,
"Increase oral fluids to 2000cc/day."
Use your nursing judgment to develop appropriate interventions.
Remember that the client is an essential part of this process. We cannot act alone
and plan outcomes and interventions FOR a client. Interventions must be planned
WITH the client.
For actual diagnoses – remember the 3 part diagnostic statements – interventions will
focus on the "r/t" (etiology) of the problem. For example:
Activity intolerance r/t shortness of breath secondary to emphysema AEB
RR 46 when ambulating
Interventions will focus on the shortness of breath. When the shortness of breath is under
control, the client will be able to ambulate. An intervention might focus on teaching
pursed lip breathing (if the assessment indicated that he/she did not already know how to
do it). An intervention for teaching purse lip breathing would include a specific teaching
plan complete with each step needed (e.g., dates, pamphlets).
For risk diagnoses – there are 2 parts, the label and the risk factors (i.e., the r/t part) –
interventions will focus on reducing risk factors to prevent the occurrence of a problem. If
the risk factors are reduced, it is less likely that the problem will develop. For example:
Risk for injury (fall) r/t weakness.
Interventions would focus on improving the weakness.
For possible diagnoses, write interventions that indicate what extra data is needed to
make a decision about the possible problem. Interventions might suggest how to collect
that data.
For collaborative problems, interventions will include both independent and
interdependent nursing actions. They will provide directions to either monitor for a
change in the client's condition, direct a change, or evaluate a response. For example:
PC: Septicemia
Interventions might include: Giving IV antibiotics on time and monitoring for
complications of the disease and/or treatment. It might also include preparing the client
for home IV care.
Remember, when you write interventions for either nursing or collaborative diagnostic
statements, you need to be so specific that other nursing personnel know what is
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expected. Date the interventions, use directive verbs, be specific about what should occur.
Who will do what, how well, under what circumstances, and by when. Sign(or initial) the
intervention.
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Nursing Process – Implementation and
Evaluation: Learning Module #5
Purpose
This module ends the series on nursing process. The learning module
focuses on the last two steps of the nursing process: implementation
and evaluation. During implementation the nursing play is actually
carried out. During evaluation the client's responses to the nursing
care (i.e., interventions) are assessed and compared to the goals or
outcome criteria to see whether they were met.
Objective


Learning
Activities
1. First review Potter (2009), Chapters 19 and 20--and read
below.
2. Remember ER? The client in the case study? Although it is
impossible to evaluate the outcomes using a case study, please
suggest:
a. When and how you would go about evaluating the
outcomes for each of the diagnostic statements and
what you would expect to see if this was really your
client and the outcomes had been met.
b. How you would know if each of the interventions you
developed for ER were working.
3. Discuss on Blackboard Discussion Board by the assigned
date.
Describe the circular nature of the nursing process.
Describe the process to evaluate whether outcomes have been
met.
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THE EVALUATION
The evaluation phase of the nursing process occurs continuously. As a nurse, you are
constantly evaluating how the interventions are going, how the client is tolerating them.
You are constantly evaluating how much progress is being made toward the
outcome/goal. For the purposes of the academic exercise of writing a nursing care study,
when we refer to evaluation we are referring to the act of assessing the client in terms of
the goal/outcome at the end of the time period specified in the goal/outcome statement.
For example, if the goal/outcome statement was:
The client will state 3 reasons to call the physician by discharge.
Before discharge you or your designee would ask the client to state 3 reasons to call the
physician. If the client could correctly do this, the goal was met. However, if the client
was unable to state 3 reasons to call the physician, the process must be reassessed,
modifications made to the care plan, the new interventions put into action, and an
evaluation done again.
There are numerous questions that you might ask when reassessing the client. Some of
the questions that you might ask include:
1. Was the goal wrong?
2. Is the appropriate person the family member (caretaker) instead of the client?
3. Maybe the client just needs to know where to get the information (on the
discharge instructions).
4. Was there enough time to meet the goal? Maybe the client needs to have one
more day, or maybe the client can be evaluated at the first home health visit that
will occur later in the day?
5. Was the intervention wrong? Maybe the time of day the teaching occurred was
not right.
6. Maybe the educational method was wrong for this client?
7. Maybe the teaching never occurred.
These things must all be assessed to determine what the next step should be. (Please
remember that in the real world you will be assessing your client's progress frequently in
order to recognize way before discharge when goals or outcomes are not going to be met.
This realistically gives you time to modify the plan)
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Fluid/Electrolytes and Acid-Base ReviewLearning Module #6
Purpose
This module is devoted to reviewing fluid, electrolyte and acid-base
balance.

Objectives
Learning
Activities
I.
Review basics related to fluid, electrolyte and acid-base
balance.
Complete the "Fluid, electrolytes and acid base review”
assignment at the end of this learning module. Answer the
questions and post on Blackboard for module #6 by the
due date.
The review is open book. It is an individual assignment.
II.
Throughout the semester many of the exercises you've been
asked to work through have had some relationship to fluid
balance. Use the information you've pulled together for those
exercises as resources for this review.
III.
Text resources:
Potter and Perry, (2009), Ch. 41
Lewis, (2007), Ch.17
IV.
Complete the case study and turn in to instructor.
Name:
Fluid, Electrolyte, and Acid-Base Review
24
1. Describe the function of albumin and hydrostatic pressure in capillary dynamics. Explain the
purpose of fluid movement in capillary dynamics.
2. List the usual daily fluid gains and losses.
3. Discuss Isotonic, Hypotonic, and Hypertonic solutions. What are colloids? What are
Crystalloids?
Fluid and Electrolyte Case Study
Patient Profile
Fiona Masala is a 58 year-old woman scheduled to undergo a bowel resection to correct a
bowel obstruction. She reports that she has vomited everything she has attempted to eat or drink
over the last 24 hours. Her abdomen is large & distended. Her vital signs are BP – 96/50, P –
118, R – 22, & T – 101.8° F oral. The physician orders insertion of a gastric tube & initiation of
gastric suction.
Significant Lab Results
 Serum Electrolytes:

Arterial Blood Gas:
Na – 143 mEq/L
K – 2.8 mEq/L
Ca – 5.0 mEq/L
Mg – 2.0 mEq/L
Cl – 98 mEq/L
pH – 7.49
PaCO2 – 44
HCO3 – 29
PaO2 – 68
O2 Sat – 96%
BE – +3
1. Evaluate Fiona’s fluid and electrolyte status. What is the most likely etiology of this
imbalance?
(1pts)
2. Identify at least five nursing assessments that you would conduct to evaluate Fiona’s fluid
and electrolyte status.
(2pts)
3. Which electrolyte disturbance is Fiona at risk for due to gastric suction?
(1pts)
25
4. Evaluate each of Fiona’s serum electrolytes? Which ones are abnormal and why?
(1.5pts)
Evaluate Fiona’s arterial blood gas, what is your interpretation? Why do you think this has
occurred?
(1.5pts)
Discuss the role of aldosterone in the regulation of fluid and electrolyte balance. How will
changes in aldosterone affect Fiona’s fluid and electrolyte imbalances?
(2pts)
Patient Profile Continued
Fiona is operated on for a bowel resection at 1100. At 1800 on the day of the surgery,
Fiona’s vital signs are: BP – 80/50, P – 130 irregular, R – 26, T – 100.1° F oral. Her surgical
dressing and bed linen are saturated with serosanguineous drainage. You quickly assess the
Fiona and inform the physician of your findings. The physician orders a STAT electrolyte
panel and a 250cc bolus of albumin (a blood volume expander) over 1 hour. In addition, the
IV rate is increased to 200cc/hr.
5. Identify the clinical signs that would indicate that this treatment has been effective.
(2pts)
6. Fiona’s serum potassium level is 2.5 mEq/L. What clinical signs & symptoms is she
demonstrating that correlate with this laboratory finding?
(1pts)
7. To correct Fiona’s serum potassium level of 2.5 mEq/L, the physician orders 4 doses of
supplemental potassium to be infused slowly as an IV additive with the post-operative IV of
D5½NS. A recheck of the potassium level is ordered for the 0800 the following day. At the
0800 recheck, the serum potassium level is reported at 4.8 mEq/L. State the tonicity of the
D5½NS. What is an appropriate response to this lab finding?
(2pts)
8. Develop a plan of care for Fiona while she is in the hospital. What daily assessments should
be included in this plan of care?
26
(2pts)
9. Identify 2 NANDA diagnoses for Fiona and one intervention for each nursing diagnoses.
(4pts)
27
Client Education-Module#7
Purpose
Gain an understanding of how client education enhances optimal
health.
Objective


Learning
Activities
1. Read Potter and Perry, Chapter 25.
Identify patient client learning needs.
Initiate client education
2. Read Lewis, Chapter 5.
3. Review the sample teaching plans on blackboard under
assignments.
4. Following the teaching plan format complete and turn in a
teaching plan for who/are caring for in the clinical setting.
28
ADMINISTERING MEDICATIONS BY
INTRAVENOUS BOLUS LEARNING MODULE #8
Read Lewis, 288-290, Central Venous Catheters. Using an Internet search, research the
latest procedure for changing central venous line (CVL) dressings. Post your findings
online under module #8.
Make appointment for lab practice if you would like to practice completing a central
venous dressing change.
29
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