UNIVERSITY OF NORTH ALABAMA COLLEGE OF NURSING

ADULT HEALTH NURSING 1 - NU 304

DATE OF CLINICAL EXPERIENCE _________ NURSING PROCESS FORM STUDENT’S NAME: Elizabeth Pierce

Nursing Goals (Planning) (3) Nursing Interventions Rationale for Interventions Evaluation of Goals
Diagnosis * must list sources
Ineffective airway The patient will improve airway 1. Assess respiratory rate, depth, 1. Establishes Partially met
clearance RT clearance within the next 6 hours rhythm, effort, and breath sounds standards to detect
increased AEB: every 4 hours. early signs of • Adventitious breath
production of compromise sounds were noted
2. Use high Fowler’s position and
respiratory • Patient has clear breath support patient’s arms. to aid in (Taylor, Ralph, after 6 hours
secretions AEB: sounds bilaterally (1,4,5) 2003, p.7).
persistent cough, breathing, chest expansion and
ventilating basilar lung fields. • Resipirations
wheezes and 2. Aids in breathing,
dyspnea.
• Normal resp. rate, easy stayed around 20.
and un-labored (1,2) 3. Help patient turn, cough, and deep chest expansion
breathe every 2-4 hours and ventilation of • Patient did have
HR: 57 basilar lung fields
• Patient coughs effectively productive cough.
B/P: 100/74 4. Suction as needed (Lewis,
expectorating sputum. Sputum was
O2:96% Heitkemper,
(1,3,5,6,7) expecorated.
Temp:97.2 5. Perform chest physiotherapy every Dirksen, O’Brien,
Resp:22 Bucher, 2007,
2-4 hours • Airways remained
• Airways remain patent. p.651). patent.
History: (1,2,4,5,8) 6. Encourage fluid when indicated.
COPD
Tobacco use 3. Helps to prevent
7. Provide tissues and paper bags for pooling of
Diabetes hygienic sputum disposal as secretions and to
needed. maintain airway
Dyspnea on
exertion and at patency (Lewis, et
8. Administer medications as al., 2007, p.646).
rest
indicated: bronchodilators
Productive cough 4. Stimulates cough
and clear airways
Sputum: dark (Taylor, et al.,
yellow/gold 2003, p. 7).

Exipratory 5. Enhances
wheezes bilaterally mobilization of
secretions (Lewis,
Rales at base of R et al., 2007,
p.646).
Chest Pain 10 on
a scale of 0-10 6. Ensures adequate
hydration and
loosens secretions
(Lewis, et al.,
2007, p.651).
 7. Helps to prevent
spreading of
infection (Taylor, et
al., 2003, p. 7).

8. Help to break up
secretions and
open airways for
easier breathing
(Lewis, et al.,
2007, p.651).

References

Lewis, S.L., Heitkemper, M.M., Dirksen, S.R., O’Brien, P. G., Bucher, L. (2007). Medical-surgical nursing: Assessment and management of clinical problems (7th ed.).

St. Louis, MO: Mosby Elsevier.

Taylor, C.M., Ralph, S.S. (2003). Nursing diagnosis cards (10th ed.). Philedelphia, PA: Lippincott Williams & Wilkins.
 REV 8/09 UNIVERSITY OF NORTH ALABAMA COLLEGE OF NURSING
ADULT HEALTH NURSING 1 - NU 304

DATE OF CLINICAL EXPERIENCE _________ NURSING PROCESS FORM STUDENT’S NAME: Elizabeth Pierce

Nursing Goals (Planning) (3) Nursing Interventions Rationale for Interventions Evaluation of Goals
Diagnosis * must list sources
Ineffective Patient demonstrates an increase 1. Monitor quality of all pulses Partially met
Peripheral tissue in tissue perfusion during the next every 4 hours.
1. Assessment is
perfusion R/T: 6 hours AEB: needed for
ongoing • Peripheral pulses
decreased blood • Peripheral pulses strong 2. Monitor extremities for edema were symmetrical
flow AEB: comparisons; loss
and symmetrical 2+ (1,2) every 4 hours. but diminished 1
intermittent of peripheral
claudication and pulses must be
• Peripheral edema not 3. Do passive range-of-motion reported or treated • No peripheral
decreased pedal present (2) edema
(ROM) exercises or ambulate immediately(Lewis,
pulses.
every 2 to 4 hours as patient et al., 2007,
• Patient will ambulate or can tolerate. p.748). • Patient performed
HR: 57
perform ROM exercises ROM exercises
B/P: 100/74
every 4 hours at his 4. Provide warmth to legs/ keep 2. Edema is a sign of and ambulated 10
O2:96%
tolerance. (3) room warm. Alternate with poor tissue feet to and from
Temp:97.2
periods of no heat added. 2-4 perfusion. Early bathroom
Resp:22
• Feet remain clean and hours detection can
clear from pressure areas. prompt effective • Patients feet were
History:
treatment (Lewis, clean and free from
CAD (5,6) 5. Continue anticoagulation
et al., 2007, pressure areas
CABG medications as ordered.
Tobacco use p.748).
2 stents in L leg 6. Assist patient in position
1 stent R leg changes every 2 hours.
3. Promotes
MI vasodilatation and
Diabetes increased
7. Assist patient with proper foot
circulation (Lewis,
care daily. et al., 2007,
Pulse Grading:
R Radial: 1 p.905).
L Radial: 1
R Pedal: 0 4. Exercise helps
L Pedal: 0 prevent venous
stasis and helps to
Claudication: Pain get adequate
in legs on walking. circulation in lower
Pain subsides extremities (Lewis,
upon sitting. et al., 2007,
p.902).
Thick brittle nails
5. Help prevent and
treat blood
clots(Lewis, et al.,
2007, p.912).
 6. Helps to prevent
ulcers and
pressure spots on
legs and body
(Taylor, et al.,
2003, p.192a).

7. Helps to prevent,
drying, cracking
and skin
breakdown on feet
(Lewis, et al.,
2007, p.905).

REV 8/09

References

Lewis, S.L., Heitkemper, M.M., Dirksen, S.R., O’Brien, P. G., Bucher, L. (2007). Medical-surgical nursing: Assessment and management of clinical problems (7th ed.).

St. Louis, MO: Mosby Elsevier.

Taylor, C.M., Ralph, S.S. (2003). Nursing diagnosis cards (10th ed.). Philedelphia, PA: Lippincott Williams & Wilkins.
 UNIVERSITY OF NORTH ALABAMA COLLEGE OF NURSING
ADULT HEALTH NURSING 1 - NU 304

DATE OF CLINICAL EXPERIENCE _________ NURSING PROCESS FORM STUDENT’S NAME: Elizabeth Pierce

Nursing Goals (Planning) (3) Nursing Interventions Rationale for Interventions Evaluation of Goals
Diagnosis * must list sources
Acute Pain RT Patient will demonstrate a relief in 1. Evaluate pain: assessing type and 1. This is done in order to Partially Met
myocardial pain within 6 hours AEB: level (intensity, location, radiation, accurately evaluate,
ischemia AEB: by duration, and precipitating and treat, and prevent • Patient
patient stating pain • Patient will describe and alleviating factors) every 2 hours further ischemia. described pain
is 10 on a scale of rate pain as a 6 or less on (Lewis, et al., 2007, and rated it as
0-10. a scale of 0-10. (1,2,3,4) 2. Asses vitals for signs of pain (heart p.811). an 8 on a
rate, and B/P) ever 4 hours scale of 0-10.
HR: 57 • Patient identifies factors 2. Vital signs will change
B/P: 100/74 that intensify pain. (1) with signs of pain. HR • Patient
O2:96% 3. Verbal and non verbal
communication with patient should will increase as well as identified
Temp:97.2
Resp:22 • Patient will state an be positive and supportive B/P (Lewis, et al., 2007, ambulation as
increase in comfort and p.797). a factor that
Apical pulse: 56 increased
decrease in frequency, 4. Ask patient to rate pain on a scale
duration and severity of 3. Patients in pain are pain.
History: of 0-10 (10 being the worst pain
CAD pain. (1,2,3,4,5,6,7,8) possible) every 4 hours sensitive to being
judged. Negative • Patient stated
MI
• Patient describes 5. Arrange for periods of uninterrupted messages verbal and that he was
DVT
appropriate interventions rest. nonverbally can comfortable
for pain relief. (7,8) interfere with and his pain
Mood and affect
6. Help patient into a comfortable therapeutic was lessening.
anxious (6 on a
scale of 0-10) and position and use pillows to help communication (Taylor,
splint or support painful areas. et al., 2003, p. 12a). • Patient
irritable
understood
7. Implement alternative pain-control 4. This is done in order to and listed pain
Dyspnea on
techniques. (Deep breathing accurately evaluate and interventions.
exertion and at
rest techniques, distraction, massage…) treat pain. (Lewis, et al.,
2007, p. 813).
Radiating pain 8. Administer prescribed medication to
(Chest, L Side and alleviate/prevent pain as ordered. 5. Promotes health and
back) 10 on a well being. (Lewis, et
scale of 0-10 al., 2007, p.812).
Patient described
as” dull constant 6. Reduces muscle
pressure” tension and pressure
on body parts (Taylor,
Nausea et al., 2003, p. 12a).

7. Nonpharmacological
techniques can be used
along with medications
to control pain (Taylor,
 et al., 2003, p. 12a).

8. Promotes adequate
pain relief (Lewis, et al.,
2007, p.811).

REV 8/09

References

Lewis, S.L., Heitkemper, M.M., Dirksen, S.R., O’Brien, P. G., Bucher, L. (2007). Medical-surgical nursing: Assessment and management of clinical problems (7th ed.).

St. Louis, MO: Mosby Elsevier.

Taylor, C.M., Ralph, S.S. (2003). Nursing diagnosis cards (10th ed.). Philedelphia, PA: Lippincott Williams & Wilkins.
 UNIVERSITY OF NORTH ALABAMA COLLEGE OF NURSING
ADULT HEALTH NURSING 1 - NU 304

DATE OF CLINICAL EXPERIENCE _________ NURSING PROCESS FORM STUDENT’S NAME: Elizabeth Pierce

Nursing Goals (Planning) (3) Nursing Interventions Rationale for Interventions Evaluation of Goals
Diagnosis * must list sources
Activity intolerance Patient will demonstrate a gradual 1. Discuss with patient the need for 1. Communicates to Partially met
R/T fatigue increase in activity tolerance within activity. the patient that
secondary to the next 6 hours AEB: activity will • Patient stated
decreased cardiac 2. Encourage patient to help plan improve physical the desire for
output and tissue • Patient state a desire and activity progression, including and psychosocial more activity
perfusion AEB: understanding to increase activities the patient considers wellbeing (Taylor, and the
fatigue, dyspnea and activity gradually. essential. et al., 2003, p. 2). understanding
dizziness with (1,2,3,4,6) for a gradual
minimal activity. 3. Instruct and help patient to alternate 2. Motivation is increase in
periods of rest and activity. activity.
HR: 57
• Patient will report a enhanced if the
decrease of dyspnea on patient participates
B/P: 100/74 4. Identify and minimize factors that in goal setting. • Patient still
exertion (4,5)
O2:96% decrease patient’s activity Patients are more had dyspnea
Temp:97.2 tolerance. willing to take part on exertion
Resp:22 • Patient will be able to
in the activity if
ambulate without any 5. Monitor physiologic responses to • Patient did not
they helped plan it.
History: dizziness (5) increased activity (including feel dizzy
Helps with self-
CAD respirations, heart rate, rhythm and esteem (Lewis, et during all
COPD • B/P, Pulse and B/P, dizziness) al., 2007, p.810, times of
Tobacco use respirations will stay within 812). ambulation
2 stents in L leg baseline limits(3,6) 6. Teach patient to conserve energy
1 stent R leg while performing ADLs. • B/P and pulse
MI
3. Conserves energy
and promotes were noted as
Diabetes low
healing (Lewis, et
al., 2007, p.812). respirations
Dsypnea on noted around
exertion and at 20.
rest 4. Helps gradually
increase activity
Patient level (Taylor, et al.,
complained of 2003, p. 2).
dizziness while
ambulating 5. To ensure rates
will return to
Claudication: Pain normal within
in legs on walking. minutes after
Pain subsides exercising (Taylor,
upon sitting. et al., 2003, p. 2).

6. Conserves energy
and promotes
healing (Lewis, et
 al., 2007, p.812).

REV 8/09

References

Lewis, S.L., Heitkemper, M.M., Dirksen, S.R., O’Brien, P. G., Bucher, L. (2007). Medical-surgical nursing: Assessment and management of clinical problems (7th ed.).

St. Louis, MO: Mosby Elsevier.

Taylor, C.M., Ralph, S.S. (2003). Nursing diagnosis cards (10th ed.). Philedelphia, PA: Lippincott Williams & Wilkins.