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Defining
Characteristics
Subjective:
I dont have
pain, I go
number one in
the morning and
late in the
afternoon
Objective:
Lab results were
RAC(08/04)
2.) Monitor
for changes in
mental status.
Date:
10/22/12Date:10/27/12
Time:
_0930_Time:0930____
Evaluative Statement:
Improve lab results within
normal limits.
Pt lab results are
improving.
Goals partially met
continue with plan of
care.
RATIONALES
1.) Long-term
hypertension can cause
decreased renal
perfusion; it also can be a
symptom of decreased
renal function.
REFLECTION/SELF
ASSESSMENT
I found this care
plan to be a little
challenging
because many of
the nursing
diagnosis could
apply. I chose this
particular one
because I thought it
encompassed most
of his medical
diagnosis,
especially safety.
Also not knowing
about the specific
labs was
frustrating.
Caring for this
patient was
challenging
because the
medications he is
on affect his
physical mobility,
i.e. Uncontrollable
hand shaking. This
increases the
difficulty for him to
feed himself.
Also he wants to
not with in
normal range.
BUN-57
Creatinine-1.3
(toward the
high
limit=dehydratio
n)
RAC(08/04)
le
A
Severely compromised
Substantially compromised
Moderately compromised
Mildly compromised
Not compromised
range
range
range
range
range
Not adequate
Slightly adequate
Moderately adequate
Substantially adequate
Totally adequate
10 and over
7-9
4-6
1-3
None
Extensive
Substantial
Moderate
Limited
None
None
Limited
Moderate
Substantial
Extensive
Never positive
Rarely positive
Sometimes positive
Often positive
Consistently positive
Very weak
Weak
Moderate
Strong
Very strong
Never demonstrated
Rarely demonstrated
Sometimes demonstrated
Often demonstrated
Consistently demonstrated
Severe
Substantial
Moderate
Mild
None
Poor
Fair
Good
Very good
Excellent
Somewhat satisfied
Moderately satisfied
Very good
Excellent
Consistently demonstrated
Often demonstrated
Sometimes demonstrated
Rarely demonstrated
Never demonstrated
* Johnson, M., & Maas, M. & Moorhead, S., (2004), Nursing Outcomes Classification (NOC), (3 rd ed.), St. Louis: Mosby, p. 44-48
RAC(08/04)