: Nursing Assessment Nursing Evaluation (Subjective and objective information about the client) Nursing Diagnosis Planning/Goals Nursing Interventions (NANDA, Maslow) (Brief SMART statement(s) (Actions taken by
: Nursing Assessment Nursing Evaluation (Subjective and objective information about the client) Nursing Diagnosis Planning/Goals Nursing Interventions (NANDA, Maslow) (Brief SMART statement(s) (Actions taken by nurse, (A statement identifying describing short-term and supported by the actual or potential long-term client-centered evidenced-based rationale problem observed from outcomes) found in peer-reviewed assessment, related to “CLIENT WILL” texts/articles/professional as evidenced STATEMENTS organizations/official by org/govt. websites) “NURSE WILL” STATEMENTS (Objective measurement that the client’s goals have or have not been met; the plan is or is not working; nurse’s actions have or have not been effective) Objective Data: Subjective Data: “can’t walk without ” “Losing independence” “overwhelmed” I
Millie Larsen Sleep disorder- Patient gets around 5-6 hrs of sleep per night. Cat snuggles patient which makes it better and not having husband sleep with her makes it worse. Sometimes cat wakes up patient in middle of night due to wanting attention. I Problems eating- Yes, has trouble cooking big meals because cannot stand for long periods of time due to bad knees. The daughter is ing with getting groceries and sometimes cooks for her. Pain is coming from knees due to just old age. Possible arthritis. No trouble swallowing can typically eat anything. No dentures Incontinence- Cannot bowel movements. Urinates often due to laughing which caused uti. Needs bedside commode due to bad knees/pain. Not comfortable going to bathroom alone. Needs assistants. Confusion- Experienced a lot of confusion in hospital. Possible confusion due to medications. Evidence of falls- No falls within the last 6 months. Uses a walker to get around due to bad knees. sometimes feels like assistance is needed. Daughter dina s get around. Cat can cause tripping hazard. House is a bit cluttered due to not being able to get around much. Possible dizziness due to medications. Steep stairs can cause possible tripping hazards. Skin breakdown- Redness of the skin due to uti and leakage. Doesn’t use lotion often which causes skin breakage. The leakage causes skin breakage around upper thigh. Has lots of moisture build up. Bad odor is a huge problem.
homework done and I don’t think his grades are very good. I know Dina worries about him. Megan is 12 and she is such a sweet child. She likes to me with my roses in the summer. I went to the doctor last week to get my blood pressure and my cholesterol checked. He wants to start me on a new pill for cholesterol. I already take about six or eight pills every day. I hope this new pill isn’t too expensive, I already have to pay a lot for my medications and I don’t get the pension anymore since Harold died. I don’t know how Harold paid all the bills, it doesn’t hardly seem like there’s enough money for all that medicine. I am lucky that I can still get around pretty well and my house is not too big. My knees are pretty bad; I think they are just worn out. They hurt a lot. I am ful that I can still tend my roses. My bladder isn’t as good as it used to be, I have to use Depends now and I worry that someone will notice the odor. I can’t laugh anymore; the leakage is getting so bad. But things like that happen when you get to be as old as I am. I can’t complain.” Simulation Scenario 1: Several weeks have passed since the clinic visit, and Millie is now in the hospital with a diagnosis of urinary tract infection and dehydration. Her presentation is atypical and she is confused. Perform a SPICES assessment based on the following information: The time is set at the 3:00 PM shift change. Millie has been in her room on the medical-surgical unit for about six hours. She was in the Emergency Department overnight because there were no available beds on the medical units. Due to her confusion, Millie did not take her medications properly in the days prior to admission and as a result, her blood pressure is very elevated. Millie’s daughter, Dina is at the bedside and is quite concerned about the confusion and elevated blood pressure.
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