Student initials: RS Date(s) of care: 4/4/09

Assessment Nursing Diagnosis Goals & Expected Outcomes Nursing Interventions Evaluation
(Supporting data) (NANDA diagnostic (Realistic, timed, measurable) (Strategies or actions for care) (Client’s response to nursing actions
statement) & progress toward achieving
goals & outcomes)
Subjective: Pt will not experience any  Monitor VS for ↑ HR, ↓ BP
Ineffective protection bleeding or bruising during  Monitor PT, INR, heparin Pt remained free from injury
r/t suppression of hospital stay levels throughout hospital stay
natural clotting ability  Monitor for occult and frank
aeb lab studies Pt will verbalize understanding bleeding: Pt’s VS remained at baseline
of bleeding precautions by end • Bruising
of shift • Epitaxis Pt stated understanding of
• Bloody gums bleeding precautions r/t
Objective: Pt’s VS will remain at baseline heparin/warfarin tx
• Bloody stools or emesis
during hospital stay
• Petechiae, purpura
PTT 86.9 Pressure was applied for 5
Any bleeding will stop within  Test stool and emesis for min. p every blood draw
10 minutes of intervention occult blood
 Encourage pt to ambulate Stool cultures remained neg.
carefully, call for help to for blood
bathroom in order to reduce
fall risk
 Keep pts most-used items
within reach
 Avoid injections if possible;
hold pressure for 5 min. after
any necc. puncture
 If bleeding occurs from
trauma, apply pressure, ice,
and/or hemostat agents
 Instruct pt to brush teeth with
soft-bristle brush, shave with
electric razor
 Encourage pt to obtain and
wear a Medic-Alert bracelet
 Teach pt/family about
bleeding precautions

1
 Student initials: RS Date(s) of care: 4/4/09

Assessment Nursing Diagnosis Goals & Expected Outcomes
(Supporting data) (NANDA diagnostic (Realistic, timed, measurable)
statement)
Subjective: Pt will use pain rating
scale to identify current
Pain c/o pain 6/10 on pain level, determine
last shift “acceptable level” of pain
during initial nursing
assessment
Objective: Pt will function on
acceptable ability level
Hx of low back injury Chronic pain r/t with minimal interference
musculoskeletal from pain and medication
abnormalities AEB side effects during shift (if
frequent c/o pain is above acceptable
unrelieved pain level, pt will take action
that decreases pain or
notify nurse)
Pt will be able to perform
Nursing Interventions Evaluation
(Strategies or actions for care) (Client’s response to nursing actions
& progress toward achieving
goals & outcomes)
 Assess and document
the intensity, Pt’s pain remained below agreed-upon
acceptable pain level throughout shift
character, onset,
duration, and
aggravating and Pt was OOB to ambulate in hall 2 times
relieving factors of during shift without aggravation of pain
pain at beginning of
shift and after any Pt reported no constipation during shift
known pain
producing procedure Pt’s VS remained at baseline
or activity, with each
new report of pain,
and at regular
intervals.
 Assess for side
effects of any
prescribed pain
medications

2
Student initials: RS Date(s) of care: 4/4/09

ADLs and ambulate in hall (constipation,

with adequate pain control
during shift
 Ask the pt to describe
 Determine the client's
sedation, ↓ appetite,
etc.)
past and current
experiences with pain
and the effectiveness
of the methods used
to manage the pain,
including experiences
with side effects,
typical coping
responses, and the
way the pt expresses
pain.
current medication
use. Obtaining a
complete history of
medications the
client is taking or has
taken can help to
prevent drug-drug
interactions and
toxicity problems that
can occur when
incompatible drugs
are combined or
when allergies are
present. The history
will also provide the
clinician with an
understanding of
what medications
have been tried and
were or were not

3
Student initials: RS Date(s) of care: 4/4/09

effective in treating
the client's pain
 Establish ATC dosing
and administer
supplemental opioid
doses as needed to
keep pain ratings at
or below the
acceptable level
 Explain to the pt the
pain management
approach that has
been ordered,
including therapies,
medication
administration, side
effects, and
complications.
 Discuss the pt's fears
of undertreated pain,
addiction, and
overdose.
 In addition to the use
of analgesics, support
the pt's use of
nonpharmacological
methods to help
control pain, such as
physical therapy,
group therapy,
distraction, imagery,
relaxation, massage,
and application of
heat and cold.

4
 Student initials: RS Date(s) of care: 4/4/09

Assessment Nursing Diagnosis
(Supporting data) (NANDA diagnostic statement)
Subjective:
Ineffective airway
Pt reports incidences of clearance r/t
SOB brochospasms and
reduced number of
alveoli AEB c/o SOB
and reduced O2 sats
Objective:
Hx of lobectomy, RAD
Goals & Expected Outcomes Nursing Interventions Evaluation
(Realistic, timed, measurable) (Strategies or actions for care) (Client’s response to nursing actions
& progress toward achieving
goals & outcomes)
 Assess resp. status at
Pt’s airway will remain beginning of shift and p tx: Pt’s O2 sat remained > 90%
patent during hospital • Breath sounds during hospital stay;
stay • RR and O2 sat supplemental O2 applied as
• Note any abnor. needed
Pt’s breath sounds will (dyspenea, cyanosis,
remain clear during retractions, access.
shift muscle use, flaring) Pt’s breath sounds remained
Establishes a baseline & clear during shift
Pt will have no monitors response to any
cyanosis during shift interventions Pt had no cyanosis during shift
 Monitor pt for signs of airway
Pt’s O2 sat will remain occlusion:
> 90% during hospital
• Cyanosis
stay
• Cessation of wheezing
• Absence of BS
• Continuous cough
 Maintain IV access ensures

5
Student initials: RS Date(s) of care: 4/4/09

route for rapid-acting

interventions
 Assist RT with breathing tx
and assess for side effects of tx
(↑ HR, tremors, anxiety)
 Provide O2 as ordered to
maintain O2 sat > 90%
 Assist pt with coughing and
deep breathing Q 2 hrs
 Encourage fluid intake assists
in liquefying secretions and
enhances ability to clear
airways
 Encourage ambulation as
tolerated