help with nursing diagnosis!!!

nocturne716 · Mar 12, 2004

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.

michw2 · Mar 12, 2004

Impaired physical mobility R/T decreased strength and endurance AEB client shortness of breath with pain while ambulating to the bathroom.

ck1o28 · Mar 12, 2004

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?

RNsweetie · Mar 12, 2004

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).

Erin

nocturne716 · Mar 12, 2004

Hypertension

Intervention:

-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)

rpbear · Mar 12, 2004

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.

RNsweetie · Mar 12, 2004

good luck rpbear

michw2 · Mar 12, 2004

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.

ck1o28 · Mar 12, 2004

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!

rpbear · Mar 12, 2004

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.

meownsmile, BSN, RN · Mar 12, 2004

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.