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RMS week two

Assessment Nursing Diagnosis Goals & Expected Outcomes Nursing Interventions Evaluation
(Supporting data) (NANDA diagnostic statement) (Realistic, timed, measurable) (Strategies or actions for care) (Client’s response to nursing actions
Rationale for interventions & progress toward achieving
goals & outcomes)
Subjective:  Pt will use pain rating  Determine whether
scale to identify the pt is
According to chart,
current pain level, experiencing pain at
pt consistently c/o
determine the time of initial
pain, often 10/10
“acceptable level” of assessment. If so,
pain during initial intervene at that
nursing assessment time to provide pain
 Pt will function on relief. Assess and
Objective: acceptable ability document the
Chronic pain r/t level with minimal intensity, character,
Hx includes
skeletal interference from onset, duration, and
multiple back
deformities, pain and medication aggravating and
surgeries, scoliosis,
therapeutic side effects during relieving factors of
osteoarthritis
procedures, and shift (if pain is above pain.
nerve damage AEB acceptable level, pt  Ask the pt to
frequent c/o will take action that describe past and
unrelieved pain, decreases pain or current experiences
and visible spinal notify nurse) with pain and the
deformity  Pt will be able to effectiveness of the
perform ADLs and methods used to
ambulate in hall with manage the pain,
adequate pain including
control during shift experiences with
side effects, typical
coping responses,
and the way the pt
expresses pain.
 Assess and
document the
intensity of pain and
discomfort after any
known pain
producing procedure
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or activity, with each


new report of pain,
and at regular
intervals.
 If the pt is unable to
report pain using
pain rating scale,
assess and document
behaviors that might
be indicative of pain
(e.g., change in
activity, loss of
appetite, guarding,
grimacing, moaning).
 Assume that pain is
present and treat
accordingly in pts
who have a
pathological
condition or are
undergoing a
procedure thought to
be painful.
 Determine the
client's current
medication use.
Obtaining a
complete history of
medications the
client is taking or has
taken can help to
prevent drug-drug
interactions and
toxicity problems
that can occur when
incompatible drugs
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are combined or
when allergies are
present. The history
will also provide the
clinician with an
understanding of
what medications
have been tried and
were or were not
effective in treating
the client's pain
 Establish ATC dosing
and administer
supplemental opioid
doses as needed to
keep pain ratings at
or below the
acceptable level
 Ask pt to describe
appetite, bowel
elimination, and
ability to rest and
sleep. Administer
medications and
treatments to
improve these
functions. Always
obtain a prescription
for a peristaltic
stimulant to prevent
opioid-induced
constipation.
 Explain to the pt the
pain management
approach that has
been ordered,
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including therapies,
medication
administration, side
effects, and
complications.
 Discuss the pt's fears
of undertreated pain,
addiction, and
overdose.
 In addition to the use
of analgesics,
support the pt's use
of
nonpharmacological
methods to help
control pain, such as
physical therapy,
group therapy,
distraction, imagery,
relaxation, massage,
and application of
heat and cold.

Assessment Nursing Diagnosis Goals & Expected Outcomes Nursing Interventions Evaluation
(Supporting data) (NANDA diagnostic statement) (Realistic, timed, measurable) (Strategies or actions for care) (Client’s response to nursing actions
Rationale for interventions & progress toward achieving
goals & outcomes)
RMS week two

Subjective:  Pt will remain free of  Thoroughly orient


Risk for Injury r/t injuries during her the client to
abnormal blood hospital stay environment. Place
profile; altered  Pt will be able to call light within reach
Objective: clotting factors; explain methods to and show how to call
altered prevent injury at for assistance;
electrolytes, home answer call light
decreased promptly.
hemoglobin, and  Keep pt’s room clear
altered mobility of hazards and keep
her favorite items
within reach.
 For an agitated pt,
consider providing
individualized music
of the pt's choice.
Calming music was
shown to be
effective in
decreasing agitation
in persons with
dementia
 If the pt is extremely
agitated, consider
using a special safety
bed that surrounds
the client. Special
beds can be an
effective alternative
to restraints and can
help keep the client
safe during periods
of agitation
 Get a sitter, to stay
with the pt to
prevent the client
RMS week two

from accidentally
falling or pulling out
tubes.
 Place an injury-
prone client in a
room that is near the
nurses' station. Such
placement allows
more frequent
observation of the
client.
 Help pts sit in a
stable chair with
armrests. Avoid use
of wheelchairs and
gerichairs except for
transportation as
needed. Pts are
likely to fall when left
in a wheelchair or
geri-chair because
they may stand up
without locking the
wheels or removing
the footrests.
 Refer to physical
therapy for
strengthening
exercises and gait
training to increase
mobility.
 Refer to occupational
therapy for
assistance with
helping clients
perform ADLs. Gait
RMS week two

training in physical
therapy has been
shown to effectively
prevent falls

Assessment Nursing Diagnosis Goals & Expected Outcomes Nursing Interventions Evaluation
(Supporting data) (NANDA diagnostic statement) (Realistic, timed, measurable) (Strategies or actions for care) (Client’s response to nursing actions
Rationale for interventions & progress toward achieving
goals & outcomes)
Subjective:  Pt’s edema will not  Monitor location and
worsen, and she extent of edema.
anxiety
Fluid volume will remain free of Generalized edema
excess r/t effusion, anasarca (e.g., in the upper
increased isotonic extremities and
 Pt will not gain
Objective: fluid retention AEB eyelids) is associated
decreased
weight during with decreased
hemoglobin and hospital stay oncotic pressure as a
HGB 90  Pt will maintain
hematocrit, result of nephrotic
HCT 25 clear lung sounds;
restlessness; syndrome. Heart
Cre 1.3
anxiety; blood no evidence of failure and renal
BUN 26
Labile BP
pressure changes dyspnea or failure are usually
and azotemia orthopnea associated with
 Pt will show no dependent edema
RMS week two

jugular vein because of increased


distention hydrostatic pressure;
 Pt will remain free dependent edema
of restlessness, will cause swelling in
the legs and feet of
anxiety, or
ambulatory clients
confusion and the presacral
region of clients on
bed rest.
 Monitor daily weight
for sudden increases;
use same scale and
type of clothing at
same time each day,
preferably before
breakfast. Body
weight changes
reflect changes in
body fluid volume.
Clinically it is
extremely important
to get an accurate
body weight of a
client with fluid
imbalance
 Monitor lung sounds
for crackles, monitor
respirations for
effort, and determine
the presence and
severity of
orthopnea.
Pulmonary edema
results from
excessive shifting of
fluid from the
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vascular space into


the pulmonary
interstitial space and
alveoli. Pulmonary
edema can interfere
with the
oxygen/carbon
dioxide exchange at
the alveolar-capillary
membrane resulting
in dyspnea and
orthopnea.
 With head of bed
elevated 30 to 45
degrees, monitor
jugular veins for
distention in the
upright position
Increased
intravascular volume
results in jugular
vein distention, even
in a client in the
upright position
 Monitor vital signs;
note decreasing
blood pressure,
tachycardia, and
tachypnea.
 Monitor serum
osmolality, serum
sodium,
BUN/creatinine ratio,
and hematocrit for
decreases. These are
all measures of
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concentration and
will decrease (except
in the presence of
renal failure) with
increased
intravascular
volume. In clients
with renal failure, the
BUN will increase
because of
decreased renal
excretion.
 Monitor intake and
output; note trends
reflecting decreasing
urine output in
relation to fluid
intake. Accurately
measuring intake
and output is very
important for the pt
with fluid volume
overload.
 Monitor the pt's
behavior for
restlessness, anxiety,
or confusion; use
safety precautions if
symptoms are
present. When
excess fluid volume
compromises cardiac
output, the client will
experience cerebral
tissue hypoxia, and
the pt may
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demonstrate
restlessness and
anxiety before any
physiological
alterations occur
When the excess
fluid volume results
in hyponatremia,
symptoms such as
agitation, irritability,
inappropriate
behavior, confusion,
and seizures may
occur