Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective

I’ve never been one to go to the doctor for anything.  I guess it’s all catching up to me now.

Objective

Problem

Ineffective health maintenance

Long Term:

Client will arrange to have a home health practitioner visit him within two weeks of discharge.

1. Student nurse will provide client information on home health services to help him choose one that will work for him.
2. Student nurse will encourage client to make appointment with home health before leaving the hospital to ensure a) he doesn’t forget and b) he has access to a healthcare team to answer questions he may have.
3. Student nurse will involve client’s wife in conversations about home health and lifestyle changes to create a support system for him.

I

Client has made appointment with a home health agency to visit his home on [date]. Client’s wife demonstrates an eagerness to help with the improvement of her husband’s health by making lifestyle changes along with him. Goal met.

The home health information provided to the client helped him find an agency that seemed to work for him financially. Client was grateful for the guidance and support.

R/T

Deficient knowledge regarding treatment and control of disease processes

Short Term:

Client will demonstrate an understanding of his condition by naming 3 lifestyle changes he will implement after discharge by 1500 on [date].

1. Student nurse will educate client on how his medical diagnoses relate to his current condition to help him better understand how the disease processes work together.
2. Student nurse will offer suggestions on lifestyle changes that may be may including diet, exercise, and diabetes maintenance that can easily be worked into his current routine to help him become willing to make changes.
3. Student nurse will make a reminder card for client to keep with him to remind him to make healthful choices daily.

I

Client seems willing to make changes to his current lifestyle and has communicated that he wishes to maintain the health he still has at 41. Client has decided that he will incorporate more fresh fruits and vegetables in his diet and will gradually start to exercise. He has started by doing ROM leg exercises and moving from the bed to the chair, and back to bed. He also mentioned that he will start getting annual flu shots and going to his physician for physical exams yearly. Goal was met.

Nursing student educated the client on the importance of personal responsibility in the maintenance of his chronic diseases and how lifestyle changes can make a vast difference in his outcomes. The education helped JN become willing to make changes to ensure a more healthful future.

AEB