|Assessment||Clinical Problem||Client Goals/Desired Outcomes/||Interventions/Actions/Order|
Patient has fallen prior to admission and was unable to get up from the floor.Objective:
Patient appears weak.
Patient holds on to objects to move from place to place.
|Risk of falls.||1a) Orient client to hospital surroundings.|
1b) Assess ability to use call bell, side rails, and bed controls.
1c) Instruct client to stand for 10 minutes prior to ambulation to avoid dizziness.2a) Make changes in the client’s environment that may lead to injury:
2b) Teach the client and her nephew the importance of the above changes.
Patient was cold on admission.
Patient has a temperature of 35 ̊C.
|Risk of hypothermia.||Patient will no longer feel cold and will achieve a normal core body temperature of 37.0 ̊C by the end of 24 hours.|
Patient’s diet has deteriorated over past months.
Patient’s nephew reports previous constipation.
Patient appears thin and neglected.
Patient has dry and coated mouth.
|Imbalanced nutrition that is less than body requirement.|
Risk of constipation.
|1a) Assess and document the patient’s dietary history, patterns of ingestion, intolerance to foods.|
1b) Provide companionship for patient while eating to encourage eating. This is because patients will usually eat more if other people are nearby at meal time (Nursing Diagnosis Handbook, Ackley and Ladwig, 2008).
2a) Assess patient for distention and presence of bowel sounds.
2b) Instruct about the significance of and encourage the client to sustain a fluid ingestion of 1.5-2 liters and eat about 25 g of fiber a day. Increase of fluid intake whilst maintaining a fiber intake of 25 g can appreciably boost the frequency of stools in patients having constipation (Nursing Diagnosis Handbook, Ackley and Ladwig, 2008).
2c) Encourage ambulation, and frequent change of sleeping position whilst in bed. Bed rest and decreased mobility lead to constipation. Minimal activity also increases peristalsis (Weeks, Hubbart & Michaels, 2000).
Problems communicating with people due to reduced hearing ability.
Client should want to acquire a hearing aid device by the time of discharge.
|1a) Assess the patient’s hearing.|
1b) Encourage the patient by giving advantages of hearing aids and emphasize on how they would improve her life.
1c) Educate the client on the use and care of hearing aids
2a) Educate the family on assisting the client in the use and care of hearing aids.
Patient complains of poor vision.
Misplacement of glasses.
Encourage the patient to acquire new pair of glasses and have a designated place to put them to prevent misplacement.
Advice on the importance of proper vision for her ambulation and preventing risk of falls.
Decreased fluid intake.
Dry and coated mouth.
Cloudy and offensive urine.
|Fluid volume deficient.|
Demonstrate adequate fluid balance A.E.B. by having moist mucous membranes, balancing intake and output, obtaining normal laboratory findings and achieving normalization of skin turgor.
|1a) Assess: Moistness of mucous membrane and skin turgor, fluid input and output every 24 hours, orthostatic hypotension 4 times a day and labs: HCT, BUN, specific gravity and sodium levels.|
1b) Encourage the patient to drink fluids frequently.
1c) Assist the patient to drink the fluids.
2) Educate patient on causes of hypovolemia, the risks involved and how to prevent it.
3) Monitor for hypervolemia during the treatment of hypovolemia. This can be achieved by auscultation of the patient’s chest for lung sounds, observing for generalized edema, and recording the vital signs(Allison & Lobo, 2004).
Nephew reports previous episodes of incontinence.
|Risk of incontinence of the bladder.||Client should be continent at all times especially during waking hours.||1a) Monitor input and output and include patterns of urinary incontinence.1b) Instruct to control urine stream during urination.|
1c) Ask the physiotherapist for pelvic floor exercises. Teach the patient how to perform each of the exercises.
1d) Limit fluids intake 2-3 hours prior to bedtime.
1e) Wake the patient up at least twice at night to void urine.
1f) Provide easy access to the urinal.
1g) Place a call light within reach always.
1h) Provide comfort measures (sit baths: warm perineal soaks as required).
1g) Establish the need for pads and diapers and identify a family member who will keep track of supplies.
Patient has a red area around the sacrum.
|Risk of pressure sores.||Client should be aware of the causes of pressure sore and how to prevent them by the time of discharge.|
Client will not acquire a pressure ulcer during her stay in the hospital.
|1a) Encourage the patient to ambulate often.1b) Shift the patient’s position on the bed every 3-4 hours.|
1c) Educate the family on the importance of the same procedure and direct them how to do it.