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Student Name:__Rachel Smith______________ Client’s orders: Include all orders Outcomes: For every order,
Date of Assignment:_2-22-11_____________________ Treatments, meds, labs results and provide the client’s outcome
Clinical Instructor:____Raatz____________________ nursing orders Provide objective and subjective
Clinical Area:_3W_____________________________ data to support your conclusions.

Client’s Initials:_PR____________ 1) Routine, vanco level daily, 1) Vanco levels stayed

Age:___57______ Sex:___F______ Ht:____5’3_________________ under 15 and doctor
if < or =15, give
Wt:_______256___ IBW:________ eventually stopped the
Admission Date:__2-16________________ vancomycin 1g vancomycin
Allergies:__gentamicin, penicillin, azactam, 2) Patient did not
2) Notify MD of
augmentin___________________________ hemorrhage or have
Primary Medical Diagnoses:____GI bleed______________ bleeding/hematoma or changes in distal pulses-
__________________________________________________ Were +1 at baseline
changes in distal pulses
__________________________________________________ vitals and stayed through
Secondary Diagnoses:__Anemia_blood loss_____________ 3) Sitz bath BID ordered out shift.
__________________________________________________ 3) Patient had sitz bath to
4) Place Central Line
Chronic Illnesses:_ESRD, CHF_______________________ alleviate and keep
Surgical Procedures (this 5) Implement High Fall Risk hemorrhoidectomy site
hospitalization):_Hemorrhoidectomy_____________ clean. Patient stated, “ It
protocol interventions.
____________________________________________ feels much better,” at end
6) Start Diabetic/Renal Diet of shift
Type of Diet:___Renal____________________________ 4) Central line placed to
7) Chest Routine PA/LAT
% of BRK eaten ___100____ avoid continually sticking
% of Lunch eaten _75_____ 8) Complete Blood Count of the patient because of
I=___656cc____ 0=____548 cc____ (past 24 hours) poor vein access.
9) Hemoglobin and
5) Fall interventions
Nutritional Considerations: (Labs, surgery, diagnoses) Hematocrit prepared. Walker was
___Renal/diabetic diet. Should be eating low calorie high protein obtained. Patient asked
10) Culture Sputum
foods. for bedside commode.
Impact of Illness & Hospitalization related to: 11) BB Crossmatch 6) Renal diet includes 1800
*Developmental Stage:_Integrity vs. Despair cal, 100 g protein, 2 g
_______________________________________________ sodium/low sodium, 2g
_______________________________________________ potassium/low potassium,
Sociocultural Factors:_African American origin prohibits the 1000cc per 24 hrs.
patients from being surrounded by nutritional eating habits which 7) X-ray of chest performed.
prevent her from making healthy diet choices. Central line placed
_______________________________________________ correctly and no
abnormal findings
8) Anemia, low
lymphocytes, and low
calcium found form
9) Hgb and Hct came back
low. Patient encouraged
to eat iron in diet. Nurse
ordered iron rich meal.
Patient started on
10) Culture sputum came
back positive for bacteria
and gram stain was
ordered do determine
what type of bacteria is in
the sputum in order to
use the right antibiotic to
treat the infection.
11) Cross match ordered for
infusion of blood after
massive GI bleed and in
case of potential


NANDA NURSING Measurable Therapeutic Nursing Interdisciplinary Team (Goals &
DIAGNOSES Client Interventions Treatment) i.e. PT, OT, RT, SW, Outcomes With
(PRIORITIZED) Outcomes With Rationales Chaplain, Dietary, MD, etc Planned Revisions for

1) Risk for infection Short-Term Goal: 1)Assess for MD, RN The patient’s fever
related to pressure The patient will see presence, existence decreased to 98.1 by the
a decrease in fever of, and history of end of the shift, and she
sore wound and
of 1-2 degrees F risk factors such as did not develop any signs
recent surgical and will not open wounds and of infection.
incision as evidence develop any signs abrasions; Each of
by low lymphocyte of infection by the these examples Patient was not
levels, elderly end of shift. represent a break in discharged during the
compromised the body’s normal shift. However, the
Long-Term goal: first lines of defense patient was able to tell
immune system,
The patient will not (Gilliespie 2009). me how to change her
decreased circulation have a normal 2) Monitor white wound dressing and
and sensation to temperature of 98.6 blood count apply the appropriate
extremities, three IV and normal WBC (WBC).--Rising topical treatments and
accesses, left arm AV lab work levels, WBC indicates state the importance of
graft, and slight and the patient will body’s efforts to hand washing to prevent
be able to repeat combat pathogens; infection of her open
fever of 99.8 at
two ways to normal values: >. wounds.
beginning of shift. prevent infection Very low WBC
by the end of (neutropenia <1000)
discharge. indicates severe risk
for infection because
patient does not have
sufficient WBCs to
fight infection. In
elderly patients,
infection may be
present without an
3) Monitor the
following for signs
of infection:
Redness, swelling,
increased pain, or
purulent drainage at
incisions or injured
sites (Hemorrhoid
incision and left
upper buttock
pressure wound).
Any suspicious
drainage should be
cultured; Levaquin
should be
administered as
ordered per
physician to prevent
4)Asses Fever. Fever
of up to (100.4° F)
for 48 hours after
surgery is related to
surgical stress; after
48 hours, fever
above (99.8° F)
suggests infection;
fever spikes that
occur and subside
are indicative of
wound infection;
very high fever
accompanied by
sweating and chills
may indicate
2009) .
5) Assess nutritional
status, including
weight, history of
weight loss, and
serum albumin.
Patients with poor
nutritional status
may be unable to
muster a cellular
immune response to
pathogens and are
therefore more
susceptible to
4) Maintain or teach
asepsis for dressing
changes and wound
care, catheter care
and handling, and
peripheral IV and
central venous
access management.
The patient should
know to change the
dressings of her
wound every day
and to look for
redness and purulent
discharge during the
dressing. The
patient should not
bathe, but take
showers and wash
the wound lightly
with soap and water.
6) Encourage intake
of protein- and
calorie-rich foods.
This maintains
optimal nutritional
status to be able
homeostasis and be
able to potentially
7) Administer or
teach use of
(antibiotic) drugs as
Antimicrobial drugs
include antibacterial,
antiparasitic, and
antiviral agents
(Patient prescribed
calcipotriene topical
ointment and
clobetasol topical
ointments). All of
these agents are
either toxic to the
pathogen or retard
the pathogen’s

2. Risk for falls The patient asked for
Short-Term Goals : assistance and used
related to impaired
Patient will call for walker for toileting
joint mobilization, assistance and use needs, and did not fall
history of falls, 2-day walker for toileting during the shift. The
post-op surgical needs and will be patient felt comfortable
procedure as toileted otherwise having the two side rails
evidence by every 2 hours to up as she slept which is
prevent fall 1) Remove excess an additional intervention
assistance with
preventions during equipment/supplies/ for the nurse to
walker for ADL’s, 21 shift. furniture from rooms implement during the
score Braden scale & hallways(Mosby shift.
indicating high risk Long-Term Goals: 2011).
fall precautions, and The patient will The patient knows to call
continue to toilet 2)Coil and secure for assistance and use the
unsteady gait and
every 2 hours and excess electrical and walker for all ADL’s,
balance. ask for assistance telephone and she knew to clear all
for rising from the wires/cords(Mosby hallways and doorways
bed or chair. The 2011). when she got home. The
patient will be able patient did not have any
to give two reasons 3)Clean all spills in falls before her
to prevent them patient room or in discharge.
from falling by hallway
discharge. immediately(Mosby

4)Place a signage to
indicate wet floor

5) Keep bed in
lowest position
during use unless
impractical (when
doing a procedure on
a patient) (Mosby

6) Keep floors
clutter/obstacle free
(especially the path
between bed and
(Mosby 2011).

7)Place call light &

frequently needed
objects within
patient reach(Mosby

8)Answer call light


patient/family to call
for assistance as
needed (Mosby

10)Assure adequate
lightening especially
at night(Mosby

Use proper fitting

non-skid footwear.
11) Apply falls risk
arm band(Mosby

12) Falling star (red)

outside the patient’s
door(Mosby 2011).

13) Falls risk sticker

on the medical
record(Mosby 2011).

14) Supervise/assist
bedside sitting,
personal hygiene and
toileting as

elimination schedule
and use of bedside
commode if
appropriate (Mosby

Gillespie, L. (n.d.). Interventions in preventing falls for the elderly in the community. Interventions for Fall and Infection that
Follows. Retrieved February 27, 2011, from

Mosby, B. . "EHS: Nursing Care Plans Risk for Infection." EHS: Nursing Care Plans. Guanlick and Myers, 1 Jan. 2006. Web.
27 Feb. 2011. <>.