help with nursing diagnosis!!!

  1. Can anyone give me an example of what I would write for evaluation of patient responses?? And what would I write to summarize my impressions of client progress toward outcomes? I'm not looking for how to do it.. I just have no idea how to phrase anything.. help pleaseeeeee.. thanks you
  2. Visit ck1o28 profile page

    About ck1o28

    Joined: Feb '04; Posts: 14
    peds RN


  3. by   nocturne716
    For evaluation....try to put qualitative and quantitative data. That's the first mistake I made, was to not put any quantitative data in.

    Like for example if you're intervention is ROM .....say that the pt. is not able to extend so and so degrees.
  4. by   michw2
    Impaired physical mobility R/T decreased strength and endurance AEB client shortness of breath with pain while ambulating to the bathroom.
  5. by   ck1o28
    hmm.. im still unsure.. can anyone tell me what i might write for an evaluation of patient responses for someone with hypertension or risk of aspiration?
  6. by   RNsweetie
    when you say an evaluation for pt response for hypertension do you mean:
    clients BP is with in normal as evidenced by last 3 reading of ..........

    I am unsue of your intervention, maybe write that and i might have some ideas (although I might not, lol).
  7. by   nocturne716

    -Administer (insert medication name) as prescribed.
    -Watch for signs and symptoms of orthostatic hypotension (side effect of hypertension).
    -Assess vital signs prior to administering medication (give or withhold as needed)
  8. by   rpbear
    Not really sure if you mean evaluations or interventions? Give us an example and maybe we can tell you if you are on the right track.
  9. by   RNsweetie
    good luck rpbear
  10. by   michw2
    What is your goals for this client. You need EO Expected outcomes before you can evaluate. I guess I am not sure of what yyou mean.
  11. by   ck1o28
    the outcome is "The client will have a decreased risk of aspiration as a result of ongoing assessment".. and if the intervention is "Auscultate bowel sounds to evaluate bowel motility." and if rationale is "Decreased GI motility increases the risk of aspiration because foods or fluids accumulate in the stomach. When combined with the weaker gag reflex, aspiration is a higher risk.".. what would be a possible evaluation of patient responses? by the way.. thanks everyone!
  12. by   rpbear
    The results from assessng the bowel sounds is your pt response, ie positive bowel sounds all 4 quads. The only thing you can write for an assessment type of intervention is the assessment. I am not sure how this is helping accomplish your goal though. I would go more along the lines of head of bed at 45 degrees at all times, or thickened fluids, or staying with pt for feedings, or assessing gag relfex before each feed or each shift.
  13. by   meownsmile
    Wouldnt you need to write evaluation of tolerating diet, ie. thickened liquids, is consistency correct for patient,elevated HOB, adequate time to swollow, amount of food given with each bite. Then regarding care between meals, HOB elevated, any suctioning needed or not needed, what was returned with suctioning, and how often suction was needed.