HOLISTIC ASSESSMENT PAGE 1

Client Initials MW Admit Date 1/21/09 Date of Care 1/29/09-1/30/09 F Age 84 Marital Status S

Diagnosis weakness, dyspnea, plural effusion, sinus bradycardia, CHF

Operation/Procedure (include date) thorocentisis (1/23/09),

Advance Directives (what type): no

Reason for admission(chief complaint) SOB

Significant History/Other pertinent information pneumonia (right lower lobe, 3 weeks PTA) , HTN, myocardial infarction, CHF, stent placement, dysrhythmias,
lipidemia, diabetes mellitus, right lower lung lobe mass (nonmalignant),
 HOLISTIC ASSESSMENT PAGE 2

Report Data: (information obtained from RN, morning report, clarification of information Plan of Care:
obtained from clinical instructor) 1. Obtain report from RN.
• Activity/Risk for Fall: up with assist, at risk for falls 2. Review chart and MAR.
3. Introduce self to Pt. and complete assessment
4. Up-to-date pt on plan of care for the day
• Allergies: NKA
5. Assist with AM care
6. administer meds
• Vital signs(frequency): TID 7. Ambulate
8. gather holistic information
9. report off to RN at end of clinical
• Code Status: full code

• Diet: Cardiac/ ADA 1800/ soft • What are the client’s top priorities regarding his or her own care for today?
-assessment/ meds-diuresis
-ambulation, OOB for meals
• IV/Saline lock: SL right hand -AM care

• Telemetry: yes (sinus bradycardia)

• I/O (last void; last bowel movement): BRP , slight urine incontinence, urine
yellow, clear; last BM 1/29. monitor I/O.
• Oxygen: RA

• Drains/Wounds: puncture wound, right middle upper back, skin intact, open to
air; stage II DU, coccyx, Allevyn wound dressing and skin barrier cream
applied 1/30/09 930; rt upper arm, ecchymotic.
• Procedures/specimens/medications: meds: 800, 900, 1200.

• Isolation: Contact precautions, hx MRSA (bronchial wash) 1/2/09.

• Scheduled Therapies/Other: PT

MEDICATIONS: TIME DUE INDICATION FOR NURSING CONSIDERATIONS

NAME RECEIVING ASSESSMENT RESULTS PRIOR TO LAB RESULTS TO MONITOR PRIOR TO ADVERSE REACTIONS/SIDE EFFECTS TO
DOSAGE MEDICATION ADMINISTRATION ADMINISTRATION ASSESS PRIOR TO ADMINSTRATION
ROUTE
Pantoprazole 900 To suppress gastric No nausea, no vomiting, no -may inc glucose, uric acid, and lipid CNS: anxiety, dizziness, headache,
(Protonix) secretions diarrhea, no constipation. No levels insomnia. CV: chest pain, peripheral
40mg (1 tablet) epigastric or abd pain. No -may inc/dec liver function edema. EENT: rhinitis, sinusitis. GI: abd
PO bloody stools or emesis. No BG:134 pain, constipation, diarrhea, dyspepsia,
headache. BUN:41 (elevated) flatulence, gastroenteritis, GI disorder,
 HOLISTIC ASSESSMENT PAGE 3

Creatinine: 1.9 (elevated) nausea, vomiting. GU: rectal disorder,

urinary frequency, UTI. METAB:
hyperglycemia, hyperlipidemia.
MUSCSKEL: arthralgia, back pain,
hypertonia, neck pain. RESP: bronchitis,
dyspnea, inc cough, upper resp tract
infection. INTEG: rash. Flulike symptoms,
infections.
Insulin Regular 800 Antidiabetic Injection site: no bleeding, no Blood glucose 830: 134 METAB: hyperglycemia, hypoglycemia.
(Novalin R vial) 1200 pain, no severe ecchymosis. Urine ketones: wnl RESP: dyspnea, inc cough, reduced
5 units -may dec magnesium, and potassium pulmonary function, resp tract infection.
SubQ injection levels INTEG: itching, rash, redness, stinging,
swelling, urticaria, warmth at injection site.
OTHER: anaphylaxis, hypersensitivity
reactions, rash.
Insulin Regular BG<150 0 units
(Novalin R vial) 151.199 2 units
Sliding Scale 200.249 4 units
SubQ injection 250.299 6 units
300.349 8 units
>350 notify MD
Aspirin (Ecotrin 900 Antiplatelet, No GI bleed/distress, nausea, -may inc liver enzymes, BUN, serum EENT: hearing loss, tinnitus GI:
81 mg) antipyretic occult bleeding, vomiting. creatinine, s. K, and may prolong dyspepsia, GI bleeding, GI distress,
81mg (1 tablet) bleeding times. nausea, occult bleeding, vomiting. GU:
PO -may dec WBC and platelet count. transient renal insufficiency HEMO:
BUN and creatinine elevated. prolonged bleeding time,
Plt count low (consistently thrombocytopenia. METAB: HEPAT:
decreasing). hepatitis. INTEG: bruising, rash, urticaria.
OTHER: angioedema, hypersensitivity
reactions (anaphylaxis, asthma) Reye
syndrome.
Magnesium 900 Mg replacement No abd pain, no diarrhea, no -may inc mag levels GI: abd pain, diarrhea, nausea METAB:
Oxide (Mag-Ox nausea. hypermagnesemia (hypotension, n/v,
400mg) depressed reflexes, resp depression, coma)
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400mg (1 tablet)
PO
Spironolactone 900 Anti-HTN (diuretic) BP: 142/58 P: 69 -may inc BUN, creatinine, K CNS: ataxia, confusion, drowsiness,
(Aldactone) No v/d/n/c. -may dec Na headache, lethargy. GI: cramping, diarrhea,
25mg PO No edema. -may dec granulocyte count gastric bleeding, gastric ulceration,
Monitor I/O -may falsely inc digoxin level vomiting. GU: impotence, menstrual
Wt Na:137 disturbances. HEMO: agranuloctosis.
K:4.6 METAB: dehydration, hyperkalemia,
Cl:100 hyponatremia, mild acidosis. INTEG:
Ca:8.1 (Low) erythematous rash, urticaria OTHER:
PT: 11.3 anaphylaxis, angioedema, breast soreness,
INR:1.08 drug fever, gynecomastia.
BUN:41 (elevated)
Creatinine: 1.9 (elevated)
Ramipril 900 Anti-HTN (ACE No cough. -may inc BUN, creatinine, bilirubin, CNS: amnesia, anxiety, asthenia,
(Altace) inhibitor) No n/v/d/c. liver enzyme, glucose, K. depression, dizziness, fatigue, headache,
2.5mg PO No headaches, lightheadedness. -may dec hgb and hct insomnia, syncope, lightheadedness,
No chest pain, no edema. K: 4.6 malaise, nervousness, neuropathy, seizures,
No abd pain. Na:137 tremors, vertigo . CV: angina, arrhythmias,
Ast: chest pain, edema, MI, orthostatic
Alt: hypotension, palpitations . EENT:
BG: 134 epistaxis, tinnitus. GI: abd pain, anorexia,
Hgb:10.6 (low) constipation, diarrhea, dry mouth,
Hct: 33.2 dyspepsia, gastroenteritis, nausea,
vomiting. METAB: hyperkalemia, weight
gain. MUSCSKEL: arthritis, myalgia.
RESP: dry persistent, tickling,
nonproductive cough. dyspnea. INTEG:
dermatitis, inc diaphoresis, pruritis, rash.
OTHER: andioedema.
Bumetanide 900 Anti-HTN (diuretic) No dizziness, no headache. Creatinine: 1.9 (elevated) CNS: dizziness, headache . CV: ECG
(Bumex) I/O balanced. BUN: 41 (elevated) changes, orthostatic hypotension, volume
1mg PO BP:142/58 BG: 134 depleteion and dehydration . EENT:
P: 69 K: 4.6 transient deafness GI: nausea GU: freq
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Lung sounds (rt. post. Lower Mg: urination, nocturia, oliguria, polyuria, renal
lobe diminished) Na:137 failure HEMO: thrombocytopenia
No peripheral edema Ca: 8.3 (low) METAB: asymptomatic hyperuricemia,
Plt count: 86 (low) fluid and electrolyte imbalance, dilutional,
hyponatremia/hypocalcemia/
hypomagnesemia, hyperglycemia,
hypokalemia, impaired glucose tolerance.
MUSCSKEL: muscle pain and tenderness.
INTEG: rash
Metoprolol 900 Anti-HTN (beta BP: 142/ 58 CNS: dizziness, fatigue, fever, lethargy .
tartrate blocker) P: 69 CV: AV block, bradycardia, heart failure,
(Lopressor hypotension, peripheral vascular disease.
50mg) GI: diarrhea, nausea, vomiting.
50mg PO MUSCSKEL: arthralgia. RESP:
bronchospasms, dyspnea. INTEG: rash

Diagnostic and/or Laboratory Test Normal Client’s Results Clinical Significance:

Values
On- Current Reason this being monitored for this What nursing interventions and clinical decisions are essential for this
Admission client. client’s care as a result of their diagnostic and/or laboratory tests?

HEMATOLOGY
WBC 4.5-11.0 10.2 12.9 Evaluation of pt with infection, Keep skin clean to avoid infections, cover open wounds, avoid
K/mm3 neoplasm, allergy or aspiration pneumonia,
immunosuppression. Pt was
recently hospitalized for
pneumonia.
RBC 3.90-5.20 3.78 3.85 Pt admitted SOB Monitor O2 sats.
L M/uL
HBG 11.2-15.0 10.2 10.6 Used as a rapid indirect
g/dL measurement of the red blood cell
 HOLISTIC ASSESSMENT PAGE 6

count.
HCT 32.8-44.7 32.7 33.2 Used as a rapid indirect
L% measurement of the red blood cell
count.
PLATELETS 125-400 115 86
K/mm3
aPTT/PTT 33.8
PT 11.3
INR 1.08
SED RATE
BLOOD CHEMISTYRY
POTASSIUM 3.5-5.1 4.2 Electrolyte is very important in the Proper dietary intake
mmol/L function of the heart and is part of
routine evaluations for pt on
diuretics or heart medications
SODIUM 136-145 137 Routinely performed. Used to Monitor I/O for fluid balance
mmol/L evaluate and monitor fluid and
electrolyte balance and therapy.
MAGNESIUM
CALCIUM 8.5-10.1 8.3 To monitor Ca in relation to serum Increase weight bearing activity. Supplements.
mg/dL albumin levels. Also electrolyte
imbalances are dangerous to the
functioning of the heart
PHOSPHORUS 2.5-4.9 4.0
Mg/dL
CHLORIDE 98-107 101 100 In correlation with other Monitor I/O
mmol/L electrolytes, Cl gives indication of
acid-base balance and hydration
status.
BUN 7-23 mg/dL 41 Indirect and rough measurement of Adequate protein intake, monitor I/O to avoid overhydration
renal function and glomerular
filtration rate.
CREATININE 0.6-1.0 2.0 Used to diagnose impaired renal
mg/dL function
BUN/CREATININ RATIO 7-23 24
TOTAL BILIRUBIN <1.0 mg/dL To evaluate liver function
TOTAL PROTEIN 6.4-8.2 g/dL 6.4 Increase intake of protein to aid in tissue reconstruction and wound
healing
ALBUMIN 3.4-5.0 g/dL 2.3 To evaluate for hepatic
 HOLISTIC ASSESSMENT PAGE 7

malfunction and nutrition

GLOBULIN 1.4-4.8 g/dL To evaluate for liver malfunction

ALBUMIN/ 1.0-1.9 g/dL To distinguish between certain

GLOBULIN RATIO diseases of kidneys and liver
TOTAL ALK PHOSPHATE 50-136 U/L
CO2 21-32 To assist in evaluating the pH
mmol/L status of the pt and to assist in
evaluation of electrolytes.
Decreased levels can be
contributed to medications
administered.
GLUCOSE 70-99 134 In evaluation of diabetic pt. Blood Monitor intake, ambulate.
mg/dL glucose levels rise as a response to
stress and several types of
medications.
SERUM LIPIDS
CHOLESTEROL
TRIGLYCERIDES
LDL’S
HDL’S
LIVER ENZYMES
ALT 30-65 U/L Used to identify hepatocellular
disease of liver.
AST 15-37 U/L Used to identify pt with suspected
coronary artery occlusive disease
or suspected hepatocellular
disease.
CARDIAC MARKERS
TROPONIN <0.4 Cardiac enzyme which is measured
for evidence of cardiac muscle
injury.
MYOGLOBIN
CK-MB
Diagnostic and/or Laboratory Normal Client’s Results Clinical Significance:
Test Values
On- Current Reason this is being monitored for What nursing interventions and clinical decisions
Admission this client. are essential for this client’s care as a result of their
diagnostic and/or laboratory tests?
BLOOD GASES
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Ph
PCO2
PO2
HCO3
URINALYSIS
COLOR Yellow Yellow
GLUCOSE Absent
KETONE Absent
BLOOD Absent
PH 4.6-8.0 5.0
PROTEIN 0-8 15
Mg/dL
UROBILINOGEN
RBC <2 9
WBC 0-4 66 Infection. Increase fluids.
URINE OSMOLARITY
SPECIFIC GRAVITY
OTHERS
CXR No
pneumothorax
Lung US Large left
pleural
effusion that
is 3cm below
skin surface.
Small rt
pleural
effusion.
Lung biopsy Nonmalignant
cells
Abd US No evidence
of renal
stenosis.
Mildly inc
contical
echogeniaty.
Suggestive of
 HOLISTIC ASSESSMENT PAGE 9

renal
parenchymal
disease.
Gallstones.
 HOLISTIC ASSESSMENT PAGE 10

NEUMAN’S VARIABLES OF ASSESSMENT (Plan of Care based on the Nursing Process)

I. PSYCHOLOGICAL VARIABLES
A. Interpersonal Communication Style
Pt is quiet and very friendly, open about medical and personal history.
B. Emotional status/Anxiety level
Coping, current outlook is good, pt is looking forward being discharged. Pt is worried about the
health status of her younger sister who is also hospitalized after a stroke. She has been keeping in tough
with her and are planning to being discharge together soon. Pt has slight anxiety and irritation because
she is not able to move about the same way she did before the previous admission in January.
C. Stress/concerns related to hospitalization
Pt’s concern is that she is unable to do self-care because she is weak, she is also concerned that
after her discharge home she will have to stay alone overnight and she might fall with no help around.
She does not want to go to an assisted living home but doesn’t not feel safe going home without the help
of her sister, who will most likely not being discharged as soon as she is to be.
D. Defense/coping mechanisms
Pt expresses her feeling by talking to her family. She has realistic views of her health and her
future and responds eagerly when discussing the importance of sitting in the chair for meals and
throughout the day.
II. SOCIOCULTURAL VARIABLES
A. Living Arrangements/Dwelling
Pt lives alone but recently, before her hospitalization, her sister has been staying with her. They
live together in an apartment with easy access to the living quarters. She does not have to walk up stairs, she
uses the elevator. Upon discharge, pt will be going back to live back at her apartment with her sister as they
have previously been living together. She has a son visits her at home frequently throughout the week. Patient
feels comfortable with this living arrangement as long as someone spends the night with her.
B. Occupation/Retired/Student
Pt is retired.
C. Support Systems
Pt is very independent. Just recently she has been relying on her sister more often. Her family
is her support system. He is available to the patient throughout the day even during working hours. I did not
observe any domestic violence behavior cues. I did not inquire about other support systems available to the
patient.
D. Educational Status
n/a – specifics did not come up in conversation. I felt that the patient was very willing to
learn how to maintain her health.
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E. Ethnic Heritage, Cultural Beliefs (other than spiritual), Customs and Health Practices
n/a – did not come up in conversation
F. Use of Complementary/Alternative Modalities of Treatment
n/a – did not come up in conversation

III.DEVELOPMENTAL VARIABLES (Erikson’s Stage)

A. Age 84

B. Life Stage Older Adult

C. Task Sense of Integrity vs. Despair

• Has your assigned client achieved previous life stage tasks and is currently showing evidence of
mastering current life stage task? Explain.
Yes, pt is open about her life and her life experiences. She believes her life was lived to its
potential. She has a health self-esteem, she discusses her son as her great accomplishment for being a caring
child that has taken her in to care for her.
• Age related risks
Depression, deprived nutrition and fluid intake, decreased activity and exercise, alcohol abuse,
Self-concept and self-image changes, change in roles and relationships, personal loss, coping strategies.

IV. SPIRITUAL VARIABLES (Religious Affiliation/Activities/Use of Belief System as a Source of Hope

and Support)
Pt is a catholic who attends church weekly. She prays often. She states her prayers give her hope.
Chart states that pt received spiritual support on 11/2/08.

V. PHYSIOLOGIC VARIABLES
A. Neurological
1. Mental Status
a. LOC: alert

b. Orientation: alert to time, place, person and situation

 HOLISTIC ASSESSMENT PAGE 12

c. Memory(short/long): no recent and remote memory deficits. Pt has no trouble recalling what she

was doing yesterday. Pt recalls clearly that she has met me yesterday also. Pt can recall memories

of when she was younger and where is lived.

d. Judgment: Pt is acting in a logical and rational manner. She is calm and cooperative. She calls for

assistance before getting up to go to the bathroom.

2. Appearance/Behavior

Pt is wearing a hospital gown with visibly good personal hygiene. Pt is weak related to her

condition. Pt is properly expressing her emotion in relation to her developmental stage. She is

cooperative and interested in our conversation. She maintains a calm manner and does not express

any feeling of anger.

3. Ability to communicate

Pt communicates clearly, does not have any noticeable speech deficits and is can be clearly

understood by the receiving party during a conversation. She maintains good eye contact and does

not speak off on tangents. Pt uses glasses. She speaks English.

4. Neurosensory
a. Vision: History of cataract removal. Eye movements are symmetrical and no amblyopia present.
Eyebrows, eyelids, and lashes intact. Pt requires glasses.

b. Hearing: Patient responds to normal speaking volume and tone. Patient does not wear hearing

aids. No discharge or excessive cerumen in ears, skin of ears intact, pink, and warm.

5. Interventions: Fall precautions, up with assistance; assistance with ADLs. Make sure patient is

wearing glasses while communicating with others or as needed.

B. Musculoskeletal
1. Gait/Ambulation: Patient ambulates with a rolling walker . Patient is ambulating safely when
walking with someone at her side to prevent falls, needs assistance of one. Gait is slightly leaning
forward, steady, slow, small steps. No shuffling gait present. No significant weakness on either side
of body. Patient has all four limbs, no prosthetic limbs.
 HOLISTIC ASSESSMENT PAGE 13

2. Alignment/Posture: Patient is slightly stooped over while walking (mainly curvature of upper spine
and neck), able to maintain proper alignment while sitting in bed, chair or walking. Patient does not
lean toward right or left side while sitting up in bed or during ambulation.

3. Immobilizing/Assistive Devices: Patient uses a rolling walker. Two side rails are up while patient is
in bed and table is positioned in front of patient wile she is sitting in chair.

4. Motor Strength (moves all extremities)

a. Symmetry: patient is moving all extremities symmetrically when prompted. Patient can move all
ten fingers and toes.

b. Strength: Lower and upper extremities are equally strong

c. Range of Motion: all active.

5. Neurovascular integrity of extremities (CMS): Upper extremities and lower extremities skin equally
slightly pale, warm and dry. Capillary refill of both upper and lower extremities 2-3 sec. Upper
peripheral pulses palpable and equally strong, in lower extremities peripheral pulses not palpable.
Patient senses light touch to extremities. No numbness, tingling or pain in any extremities.

6. Interventions: ; physical therapy to ambulate; activity every two hours ( up from bed and ambulate),

up to chair for meals; assistance with ADLs. Bed mobility: moderate assist; Transfers: minimum

assistance to stand; Gait: contact-guard assistance; Device: rolling walker; Activity with nursing: out

of bed for meals and as tolerated; Ambulate in hallway.

C. Respiratory Integrity
1. Respiration (rate, rhythm, and depth): unlabored breathing, regular rhythm, regular rate 18
breaths/minute. Eupnea. Nasal flaring absent. Pursed lips absent while breathing. Patient breathing
comfortable while sleeping, sitting up in bed, sitting in chair. While walking patient increases breaths
per minute to about 20, once activity decreased, breathing rate returns to normal at 18 in less than 5
minutes. No audible breathing sounds.

2. Lung sounds : clear except in right lower posterior lobe diminished. Pleural effusion.

3. Cough- patient is not coughing

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4. Sputum (color and amount)-patient is not expectorating any sputum

5. Assistive Respiratory Treatments/Interventions: Oxygen protocol initiated as needed: per nasal

canula 2-4L LPM – currently patient 94% on room air, no supplemental O2 need.

D. Cardiovascular Integrity
1. Vital signs

a. Peripheral pulses (rate, rhythm, quality): right arm 69 bpm; regular, strong peripheral pulse

rhythm. In lower extremities, pulse non-palpable. Patient admitted with sinus bradycardia with

symptoms and placed on remote telemetry.

b. Apical pulse: 70 bpm. Regular and strong. No murmurs. PMI located in the left 4th or 5th

intercostal space just medial to the midclavicular line.

c. BP: 142/58 right arm (0800 1/29/09). Pt currently medicated for hypertension.

d. Temperature: 97.9 degrees F, oral.

e. Pulse oximetry: 94% on RA.

2. Color and warmth: Patients body is equally slightly pale and warm.

3. Capillary refill: 2-3 sec in both upper and both lower extremities.

4. Edema (peripheral): no peripheral edema present.

5. Interventions: Remote telemetry.

E. Gastrointestinal
1. Weight, Height, BMI, Nutritional State : Ht: 5ft 6in; Wt: 132 lbs. BMI: 21.3 (healthy range) frail

stature.

2. Note condition of mouth/teeth/gums and overall oral hygiene: Remaining teeth intact, inner mouth

moist and pink. No scabbing, skin abrasion or lesion in mouth.

3. Mucous membranes (moist/dry): mouth moist.

4. Capillary Blood Glucose: 134 (800 1/30/09)

 HOLISTIC ASSESSMENT PAGE 15

5. Diet: Cardiac, ADA 1800, soft. Patient needs additional nutrients, currently in process of

assessments and changes.

6. Ability to Feed Self, Chew/Swallow: Pt does not needs set up of meal trays, able to feed self.

7. Appetite: good appetite, breakfast 11/5/08: 80% 180cc.

8. Abdomen (LOOK, LISTEN, FEEL): bowel sounds present in all four quadrants: normoactive, no

distention or abdomen, abdomen soft without pain; not tender.

9. Stool and Usual Bowel Characteristics, last BM (any changes in patterns): stools soft brown,

decreased in frequency while institutionalized. Patient has full control over bowels. No unusual

characteristics.

10. Perianal area/Rectal conditions: rectal area clean, no fissures, redness or external hemorrhoids, Stage

II DU on coccyx. Allyven wound dressing applied. Perineal area slight redness and irritation, inner

groin, Nystatin powder applied.

11. Intake/Output: intake by mouth. Output: BM with no unusual characteristics.

12. Interventions: monitor intake and output, encourage to eat during meals. Maximum assist with

bathing.

F. Genitourinary
1. Mode of elimination: Bathroom, walking and clean up with assist

2. Any changes in voiding pattern (pain/burning/frequency): no pain or burning while voiding, no

feelings of urgency, increased frequency or incomplete bladder emptying; slight incontinence

reported by pt, pt wears Depends at home.

3. Characteristics of urine: yellow, clear.

4. Intake/Output: breakfast 200cc. Output: 0800 1/30/09 – 300cc, slightly cloudy, yellow.

5. Interventions: monitor I/Os. Frequent perineal care to maintain genitalia clean and dry. Keep

dressing clean and intact, change dressing.

G. Integumentary (Skin)
 HOLISTIC ASSESSMENT PAGE 16

1. General condition (color, turgor, rashes, moisture, bruises): skin pinkish white (pt is Caucasian) and

warm, no erythema, no jaundice, . Skin turgor is slightly elastic. No rashes on body. Skin is dry to

touch, no diaphoresis, slight dryness or flakiness. Ecchymosis on rt upper lateral arm.

2. Check bony prominences/protective aids: DU stage II on coccyx, wound dressing applied.

3. Wound/Incisions/Dressing: coccyx pressure ulcer as noted above.

4. Interventions: moisturize skin with lotion to preserve elasticity and to aid in the prevent tears, dry

skin well after bathing in skin to skin contact areas (genitalia, underarms, neck, under breasts and

abdomen). Protective dressings to coccyx, elevate heels on pillow to avoid heel contact with bed to

prevent possible skin breakdown. Measure and document all wounds and abrasion daily. Activity

every 2 hrs while awake to promote circulation and skin integrity. Nutritional consult requested

regarding skin integrity issues.

VI. Discharge Planning Assessment

A. Anticipated date of discharge: patient is to be d/c home within couple of days. Date of potential

discharge was not acquired from pt.

B. Self care needs: mod assist with dressing and bathing.

C. Educational needs/Health Promotion: discuss all of discharge planning and patient education with son

who will be helping care for pt.

D. Barriers to learning: diminished and slowed motor skills due to weakness.

E. Equipment/environmental needs: rolling walker . Potentially a type of monitoring/emergency calling

device to call for help when home alone.

F. Resources for discharge: nurse to follow up with doctor

Plan upon discharge: move back to own apartment with sister.

VI. Neuman Wheel

 HOLISTIC ASSESSMENT PAGE 17

Based on the holistic variables of the individual (physiological, psychological, sociocultural,

developmental and spiritual) chart on the Neuman Wheel to depict the priority of needs based on your
assessment of the client. Give reasons for depicted priorities.

Pt is a 84 yo female. Admitted with SOB. Dx plural effusion, weakness, sinus bradycardia, dyspnea. Pt
is a catholic who prays and attends church regularly. She has a son who she relies on mostly for
emergencies. She lives alone in an apartment building which her sister also lives in. She is worried about
her sister’s current medical condition and her ability to be potentially d/c soon. She states she is
independent and able to complete her ADL independently with min assistance although she is quite
weak and does need additional help. She relies on her family and friends for support and does not belong
to any community groups.

Spiritual

Developmental

Psychological
Sociocultural

Physiological

Complete the following regarding your assigned client:

1. Explain the pathophysiology as it relates to your client’s medical diagnosis.

Transudative plural effusion is caused by some combination of increased hydrostatic pressure and decreased
plasma oncotic pressure. Heart failure is the most common cause, followed by cirrhosis with ascites and
hypoalbuminemia, usually from the nephrotic syndrome.
 HOLISTIC ASSESSMENT PAGE 18

2. What are the most important assessments (including lab values) for your client today?

Auscultate and percuss lungs for abnormalities, BP, pulse, asses for dyspnea and tachypnea,

3. What complications may occur? What could go wrong?

Large effusions could lead to respiratory failure.

4. What health promotion interventions and/or activities are essential to optimize your assigned client’s
wellness potential or condition?

Coughing and deep breathing exercises, ambulation, proper nutrition, frequent assessment to observe pt
breathing pattern, oxygen sat, for evidence of improvement or deterioration.

5. Identify three pertinent actual or potential NANDA nursing diagnoses and list in order of priority.

Ineffective breathing pattern related to collection of fluid in pleural space.

Impaired gas exchange related to right lower lung lobe mass.
 HOLISTIC ASSESSMENT PAGE 19

Medication Administration: Nursing Process Focus**

Classification/Prototype: proton pump inhibitor

Generic Name: Pantoprazole sodium Trade Name: Protonix, Protonix IV
Assessment*
• Indication(s) for client receiving Heartburn symptoms, increased stomach acid formation r/t stress of being
this medication institutionalized
• Route and dosage for this client 40mg PO Therapeutic dosage ranges: 40mg PO

• Required assessments prior to
administration with results of
assessments
• Baseline data to consider prior to
administration
• Allergies
Required: asses underlying Results of: no abd pain, no n/v. no
condition; asses pt for complaints bloody stools or emesis.
of epigastric or abd pain and for
bleeding
Serum lipid enzyme levels, liver function test.
nka

• Reason(s) to hold medication Abd pain, bloody stools or emesis, headache, pain, chest pain, peripheral
edema, c/d,n/v, uti, dyspnea, increased cough, rash.
• Reason(s) to notify M.D. Bloody stools or emesis, abd pain,n/v

• Any contraindications to the In pt hypersensitive to the drug

administration of this
medication?
• Drug-Drug or Drug-Herbal/Food Ampicillin esters, iron salts, ketoconazole, St.John’s wort, food delays
that may interact with this absorption
medication
Diagnosis*
• Identify actual/potential Nursing Risk for imbalanced fluid volume related to drug-induced adverse
Diagnosis for the client receiving reactions.
this medication
Planning: Client Goals and Expected Outcomes*
• Identify expected outcomes Pt maintains adequate hydration throughout therapy.
related to the administration of
this medication
Implementation*
Nursing Interventions and Administration Alerts Client/Family Education
-can be given without regards to food. -instruct pt take exactly as prescribed and at approx the
-monitor fluid intake same time every day. –drug can be taken with or
without food. –table is to be swallowed whole. –instruct
to report abd pain, or signs of bleeding, such as tarry
stools. – not to drink etoh, eat food or take drugs that
can cause gastric irritation.
Evaluation (effectiveness of interventions, therapeutic effects, and adverse/side effects)*
• Expected therapeutic effects Decrease gastric secretions
achieved

• Any occurrence of adverse/side Abd pain, constipation, diarrhea, nausea, vomiting, urinary frequency, inc
effects cough, rash.
 HOLISTIC ASSESSMENT PAGE 20

• Need for further client/family As above

education
Any additional documentation required in the client’s chart besides the MAR? If so, where in the client’s chart would this
data be documented? Allergies and diet.

**Adams, M. P., Holland, L. N. and Bostwick, P. M. (2008). Pharmacology for nurses: A pathophysiologic approach (2nd ed.). New
Jersey: Pearson Prentice Hall.