Data Data AnalysisActivity and Exercise A female patient B admitted into the chronic care unit for the fracture of her Right Clavicle from a fall. She needs AX1 to assist her for her transfer. The pt had right knee surgery. She has right hip arthroplasty. The pt needs assistance in bed mobility (AX2) moving up and down and rolling. The pt has no gait toleration. She needs assistance for transfer AX1 Data Cluster The pt had right clavicle fracture from a fall. The patient needs assistance (A X 1) to be transferred from her bed to wheelchair. TMT P The pt needs assistance for her movement. TMT N The nurse with the help of PSW or other support workers transfer from her bed to the wheelchair whenever needed. Data cluster The pt had right knee surgery. She went through right hip arthroplasty. TMT P The pt has physical limitation due to her knee and hip surgery, but she has some degree of strength on left side. TMT N- The nurse will encourage the pt to use her left side. For example, grabbing food with left hand. TMT N- The nurse can instruct the pt to do some active ROM exercises on the stronger side of the body and the nurse also can perform passive ROM left upper extremities of the body. TMT N- The nurse can discuss her mobility issue with the inter-professional team members (physiotherapists). Clue The needs assistance in bed mobility (AX2). Inference The nurse will schedule the pts side change while the pt in bed with the help of other nurses, so that the pt will not left for staying on one side for a long period of time. Data cluster The pt has no gait toleration and she needs assistance for transfer AX1. TMT P- The pts has mobility issue due to her physical condition (fracture). TMT N The nurse will provide the pt with isometric (static) exercise tools such as quad sets. Rationale isometric exercise strengthens abdominal, gluteal and quadriceps muscle for ambulation. Rest and Sleep The pt found waking up late morning. The pt had knee surgery and hip fracture. The pt is not able to roll from side to side independently. Does the pt drink coffee or tea in the evening Found the noisy environment. Found another pt make noises. The pt had the history of diverticulosis and hemorrhoids. It is not known whether the pt takes day-time nap. The pt had history of chronic constipation. The pt takes Docusate Sodium PO daily. Data gap What time does the pt go to bed at night What is the pattern of sleep such as waking time, sleep ritual, length of time to fall asleep and quality or satisfaction with sleep TMT N The nurse needs to inquire about this information. Data cluster The pt had knee surgery and hip fracture. The pt is not able to roll side to side. TMT P These factors can contribute to sleep quality. TMT N- The nurse will monitor time to time to ensure the comfort of the patient. TMT N- The nurse can administrate pain medication if not contraindicated. Data gap Does the pt drink coffee or tea in the evening. Does the pt take any caffeinated beverages Inference The nurse will inquire about the information regarding beverage intake before bedtime and talk with the inter-professional team whether warm milk can be served before the pts bedtime to the pt if not contraindicated. Rationale warm milk has tryptophan that can induce sleep. Data cluster Environment noisy, another pt sharing the same room speaks loudly. TMT P- Noisy environment can interfere with pts sleep. TMT N- Nurse will provide the pt with ear buds that can block noises during bedtime. Data cluster The pt had the history of diverticulosis. She has hemorroids. TMT P- The pt can experience pain and itching due to these disease conditions and they can interrupt sleeping. TMT N- The nurse will monitor the problem of the pt. TMT N – The nurse will communicate with the inter-professional team members and find out any ointment or medication can be administered to the pt to relieve the signs and symptoms of those diseases. Data gap Does the pt take day-time nap TMT N- The nurse will find out whether the pt takes day-time nap. TMT N- The nurse will encourage the pt to cut down day-time nap if any taken and to keep the pt busy in other activities the pt like to do during day time. Data cluster The pt has the history of chronic constipation. She takes Docusate Sodium TMT P Chronic constipation and bowel movement during sleeping time can cause sleep interruption. TMT N The nurse can discuss the administration of medication with inter-professional team members for administering the medication during day-time so bowel movement will be during the day time and does not interfere sleep at night. Sensory The pt had history of oral ulceration. . The pts family members sometimes visit her. The pt needs assisted mouth care. The pt is 91 years old. The pt wears glass and does not wear hearing aid. The pt takes Anastrozole 1 Tab PO daily. The pt has attention deficit disorder. The pt takes Ritalin. Cue The pt had history of oral ulceration. Inference The nurse needs to discuss with inter-professional team members for inquiring about changes of oral mucosa that causes alteration of taste buds. Cue The pts family members sometimes visit her. TMT N- The nurse can request her family members to bring food she likes while giving them food restrictions such as not bringing spicy food or food that is hard to digest. Rationale According to Kozier textbook, diet in variety of texture and flavors stimulates taste buds. Cue The pt needs assisted mouth care. Inference The nurse should provide mouth care after each meal to keep healthy oral environment. Data structure The pt is 91 years old. She wears glass and does not wear any hearing aid. TMT P The pt might encounter vision or hearing difficulties due to the aging and disease process. TMT N The nurse can bring the concern to the inter-professional team and can set an appointment with an optician or a hearing specialist for the pts current visual and hearing tests. TMT N The nurse should make sure that her pair of eye glasses are within the pts reach. Cue The pt takes Anastrozole 1 Tab PO daily. Inference The side effect of Anastrozole is dry mouth and less saliva causes the reduction of tasting materials mixed with the food. Data structure The pt has attention deficit disorder. She takes Ritalin. TMT P- The pt has poor mental status such poor attention level. TMT N- The nurse should monitor the pt from time to time and repeat the instructions. Skin and Hygiene The pt had right hip arthroplasty. She has difficulty to roll on the bed. The pt had hip and knee surgery. The pt had history of several abdominal surgery. She needs AX2 to roll on the bed. In the Braden scale, the total score is 15. She has mobility issue. The pt has incontinence. She needs total care for toileting. The VRE and MRSA tests performed and the results came out negative.Data cluster The pt had right hip arthroplasty. She has difficulties to roll from side to side. TMT P The pt risks for skin breakdown and infection. TMT N The nurse will turn the pt from one side to another q2h while the pt is on the bed. Cue The pt had hip and knee surgery. Inference The nurse needs to assist her in maintaining her hygiene such as providing bathing and oral care since the pt is not capable of doing her self-care. . Data cluster The pt had several abdominal surgery. She needs assistance (AX2) for changing position on the bed. TMT P The pt risks for pressure ulcer. TMT N- The nurse will assess the skin integrity of the pt during bathing time or pericare in regular basis. Data cluster The total score of Braden scale is 15. And she has mobility issue. . TMT P The pt has potential risk for pressure ulcer. TMT N The nurse will use friction-reducing device and get assistance needed to move the pt especially upward on the bed. Rationale Friction and shear is one of the components of Braden scale that can anticipate pressure ulcer risks. According to Kozier textbook, moving pt upward is not a one persons job and can cause shear if not done properly. Data cluster The pt has incontinence and she needs total care for toileting. TMT P- The pt risks for skin breakdown and infection. TMT N- The nurse will check for incontinence and change the pts incontinent brief as needed. Rationale moisture and enzyme in the feces break down skin and leave the skin susceptible to infection. Cue The pts VRE and MRSA tests came out negative. Inference The nurse can consult with the inter-personal team members to check for hospital acquired infections from time to time.Safety The score of Fall Assessment Tool came out to be 50 pt. It indicates the pt is at higher risk for fall (Higher risk is the score greater than 45) The pt has safety equipment such as grab bar, wheel chair and bath chair in her residence. The pt had history of fall. She had hip and knee surgeries. The pt can communicate with others in English. Her level of understanding is intact. The pt has a pair eye glasses and she does not wear hearing aid. The pt has mobility issues. She has risk for fall. The pt will be subject to discharge in an undeclared date.Data cluster The pts score for fall risk assessment is 50. Higher risk for fall is the score that is greater than 45. TMT P The pt risks for fall. TMT N The nurse will monitor the pt q2h. Cue- The pt has safety equipment such as grab bar, wheel chair and bath chair in her residence. Inference The nurse will discuss the matter with inter-professional team members and let them know about checking the safety equipments for working condition. Data cluster The pt had history of fall. She had hip and knee surgeries. TMT P The pt risks for fall due to her physical conditions TMT N The nurse will make sure that the call bell is within the pts reach and it is functioning Data cluster The pt can communicate with others. Her level of understanding is intact. TMT P- The pt has the ability to take the nurses safety instructions. TMT N- The nurse will educate her about the safety procedures such as activating the call bell and wearing footwear that are recommended by the agency. Data cluster The pt has a pair of eye glasses and she does not wear hearing aid. TMT P Not wearing eye glasses and hearing aid when needed can cause injuries and fall. TMT N The pt will educate her to use eye glasses or hearing aid when she needs to wear them. TMT N The nurse will place her important items within her reach so that she can use them at the right time. Data cluster The pt has mobility issues. She has risk for fall. TMT P The pt risks for fall. TMT N The nurse should ensure that 3 side rails are up especially during her bedtime and the side rails up when the nurse is not attending the pt. Clue The pt will be subject to be discharged in an undeclared date. Inference The nurse will discuss the matter with inter-professional team members and arrange support team members for the pt after the pts discharge. Nutrition The pt consumes 3 meals a day. She is in regular diet as tolerated. The pts current weight and past weight are not known. The pt has chronic constipation. The pt had bowel resection. The pt has the habit of alcohol consumption. She has chronic constipation. The pts likes and dislike about food are not known. exhibits difficulty in swallowing. She was in thin fluid diet. She vomited right after having the tea biscuit in the morning. The pt takes 80 mg ASA tab daily. The pt had the history of oral ulceration Data cluster The pt consumes 3 meals a day. She is in regular diet as tolerated. Data gap How much she eats in her every meal Data gap What is the nutritional value of her food intake TMT N The nurse will inquire about the information of her food intake. Data gap What is her weight now What was her past weight Data gap Does she lose or gain weight TMT N The nurse inquires about pts current and past weight. TMT N The nurse will discuss the significant weight loss or gain with the inter-professional team members. Cue The pt has chronic constipation. Inference The nurse will encourage the pt for fluid intake if not contraindicated and the nurse encourages the pt to have fiber-rich diet. Rationale According to Kozier textbook, adequate fluid intake and fiber-reach food promote bowel movement and increase her appetite. Cue The pt had bowel resection. Inference The nurse can administer pain medication according to doctors order. Rationale According to Kozier textbook pain due to bowel resection can interrupt food intake. Data cluster The pt has habit of alcohol consumption. She has chronic constipation. TMT P These factors influence negatively on the pts nutrition. TMT N The nurse will educate the pt about the alcohol effect on nutrition. Data cluster The pts likes and dislikes of food are unknown. TMT P The pt might not like food she consumes in her each meal. TMT N The nurse will ask the pt about the food she likes. TMT N The nurse will talk to the family members regarding the pts food likings. TMT N The nurse can encourage the pts family members to bring her favorite food while keeping in mind about food restrictions such as not bringing spicy food. Rationale giving the pt her favorite food might increase her appetite. Data cluster The pt takes ASA. She had the history of oral ulceration. TMT P These factors affects negatively on nutrition. TMT N- The nurse will provide oral care to the patient. Rationale According to Kozier textbook, proper oral hygiene might increase the pts taste for food. Urine Elimination The pts urinalysis is as follows colour-yellow and light turbid, specific gravity-1.014 and pH-5. The pt has urinary incontinence. The pt has a habit of drinking alcohol. The pt has a past history of UTI, Urine erythrocyte 6-10, bacteria 3. Pts experience about dysuria and nocturia are not known. The pts Glomerular Filtration Rate (GFR) is not known. How much the fluid intake of the pt a day. How much fluid output of the pt K. pneumoniae was found in pts urine culture. The C S of urine culture indicates that K. pneumoniae is sensitive to Gentamycin antibiotic. The pt had the history of rhabdomyolysis. She had acute kidney injury. Data cluster The color of urine is yellow, its specific gravity is 1.014 and its pH is 5. TMT P- The pts urinalysis turns out to be normal. The pH of the pts urine is normal. TMT N- The nurse will measure urinary output and observe any abnormalities. TMT N- The nurse will speak with the doctor for the urine test from time to time. Cue The pt has urinary incontinence. Inference The nurse should teach the pt about pelvic floor muscle exercise (Kegel exercises). Rational According to Kozier textbook, Kegel exercise help to strengthen pelvic floor muscles that can reduce urinary incontinence. Cue The pt has a habit of drinking alcoholic beverages. Inference The nurse should educate the pt about the bad effect of alcohol. Rationale According to Kozier textbook, alcohol can cause the instability of detrusor muscles and increase the risk of urinary incontinence. Data cluster The pt has a past history of UTI, erythrocyte 6-10 and bacteria 3 TMT P The pt is susceptible to UTI. TMT N The nurse should discuss the matter with inter-professional team members for urinalysis from time to time. TMT N The nurse should encourage the pt to eat protein-rich food. Rational protein acidifies urine and reduces the chances of urinary tract infection. Data gap Does the pt have dysuria Does she have nocturia Data gap What is the pts GFR. TMT N The nurse should discuss the matter with the pt. TMT N The nurse should inquire about GFR of the pt. Data gap How much fluid does the pt take in a day How much fluid output through urine TMT N The nurse will inquire about this information. TMT N The nurse will encourage the pt to take adequate fluid intake during the day if the urine output is low and if the fluid intake does not contraindicate with the pts physical condition such as edema. Data cluster K. pneumoniae was present in pts urine culture and antibiotic sensitivity was found out for that. TMT P The pt is susceptible to urinary tract infection. TMT N The nurse should speak with the inter-professional team members for urine tests. Data cluster The pt had rhabdomyolysis and kidney injury TMT P Rhabdomyolysis and kidney injury are co-related. TMT N The nurse should discuss the matter with the inter-professional team members and monitor the pt closely and routinely for urinary retention and edema. Fecal Elimination The pts stool color, odour, amount and frequency of bowel movement are not known. The pt had a history of chronic constipation The pt had bowel resection, hip and knee surgery. The pt has mobility issues. The over the counter drugs are available for the patients and the pt will be discharged in the near future. The results of stool assessments are not known. Data gap What is the pts stool color, amount and frequency of fecal elimination Date gap Does the pt use valsalva manoeuvre during defecation TMT N- The nurse will inquire about this information. TMT N The nurse should report any abnormality found in pts stool to the inter-professional team members. Cue The pt had a history of chronic constipation. Inference The nurse will encourage the pt for having fiber-rich diet and adequate fluid if not contraindicated. Data cluster The pt had bowel resection, hip and knee surgery. She has mobility issues. TMT P All those factors are related and they affect fecal elimination. TMT N The nurse will help the pt to perform isometric exercises that strengthen abdominal muscle and that can promote peristalsis. Data cluster The over-the-counter drugs are available for the patient. The pt will be discharged in the near future. TMT P The pt will have chances of taking over-the-counter drug after her discharge. TMT N The nurse will educate her to avoid over-the-counter medications to treat her constipation. Rational According to Kozier textbook, pt should avoid over-the-counter medication to promote regular defecation. TMT N The nurse should educate the pt about not ignoring the urge to defecate. Rationale According to Kozier textbook, ignoring the urge for defecation will disturb the regular defecation process. TMT N The nurse should educate the pt or family members to record of bowel movement pattern and discuss any abnormality found with the medical professional team members. Data gap Does any fecal occult blood test taken for the pt TMT N The nurse should inquire about the fecal tests. TMT N The nurse should check for any blood or abnormalities in the pts stool from time to time. Oxygen The pts breathing pattern is not known. She has past history of HTN. The pt has mobility issues due to her physical condition. She had knee and hip surgery The pt has a habit of drinking alcohol. It is known whether she smokes or past history of smoking. The pt will be discharged in the near future. Its not known whether she will live in her bungalow or senior residence after her discharge. Data gap What is the pts breathing pattern. TMT N- The nurse will inquire about the pts of breathing pattern. Cue the pt had history of HTN. Inference The nurse will monitor the pts vital sign regularly. Data cluster The pt has mobility issue and she had knee and hip surgery. TMT P The pts immobility will affect on her cardiovascular health. TMT N The nurse should position the pt in high fowler position to decrease preload. Data cluster The pt has a habit of drinking alcohol. Its not known whether she smokes or not. TMT N- The nurse can educate the pt not drinking alcohol too much (not more than 30 mL of alcohol) and not to smoke. Data cluster Its not known whether the pt will live in her bungalow or in senior residence. TMT P It is important for the pt to live in a smoking free and pollution free environment. TMT N The nurse will discuss the matter with the pts family members and inter-professional team members. TMT N The nurse will educate the family members regarding the importance of leaving the pt in a smoke-free environment. TMT N- The nurse will teach the pt abdominal and pursed lip breathing if not contraindicated. Rationale According to Kozier textbook, abdominal and pursed lip breathing promotes oxygenation. Self Concept The patient used to live in her bungalow alone. Her daughter and son live in another place with their family members in Canada. The pt is dependant on others for her ADL. She has mobility issues due to her hip and knee surgery. Does the pt belong to any religion Does the pt believe in God The pt had breast cancer. She takes medications (Anastrozole) for cancer. The pt can live in the long term care facility with the people with same age group. Compare to Norms The pt lives alone. Her daughter lives with their family. TMT P According to Eriksons stage of development, the pt will like to share with others and lacking that will hamper her self-esteem. TMT N The nurse will discuss the matter with the family members, so that they can provide some time to visit her at least twice a week. Data cluster The pt is dependent on others for her ADL. She has mobility issues due to her hip and knee surgery. TMT P- The pts dependency and physical conditions may lower her self-esteem. TMT N- The nurse will encourage the pt to involve her in her own care as much as possible. Rationale Promoting independence will enhance pts self-esteem. Data gap What type of religion does the pt belong to Does the pt believe in God Does the pt follow any ritual practice TMT N- The nurse will inquire about the information of the pts belief system. Data cluster The pt had breast cancer and she takes medication for treating her cancer. TMT P The pt needs support system in place. There is a chance of exacerbation of cancer. TMT N The nurse will discuss the matter with inter-professional team members for the support system. It will enhance the pts self-esteem. Data cluster The pt can live in a long term care facility with the same age group people. TMT P She will feel comfortable if she come across with the same age group. TMT N- The nurse will discuss the matter with the inter-professional team members, so they can come up with community help through a social worker. Rationale Sharing with the people with the same age group will enhance her self-esteem. Sexuality The pt is married. There is no information about her husband. Does the pt have abnormal discharge or discomfort The past menstruation history is unknown. It is not known whether the pt takes the diagnostic tests of mammograms and PAP tests. The pt has a daughter and a son. Any other information regarding her past pregnancy is not known.Data gap Is her husband alive Does she have any partner Does he have any concern about his sexuality Is he looking for a partner TMT N The nurse can inquire them, but the nurse will also keep in mind about maintaining therapeutic nurse-client relationship. Data gap Does the pt have abnormal discharge or discomfort What is her past menstruation history TMT N The nurse will inquire about this information. Data gap It is not known whether the pt took the diagnostic tests of mammograms and PAP tests. TMT N The nurse will inquire about this information. Data gap How many incomplete pregnancies did she have before Is there any abortion during her pregnancy in the past Was there any stillbirth baby she gave birth to in the past TMT N The nurse will inquire this information. Expected OutcomeNursing InterventionPriority Need Self-concept Nursing Diagnosis Self-Esteem, situational low, Related to immobility, hip and knee surgeries and breast cancer shown by verbalization of her inability to do regular daily activities.The pt will verbally and non-verbally display her positive attitude and self-worth during her hospital stay. The pt will adjust to change in physical limitation during her care in the hospital. 1)The nurse will encourage the pt to participate in her plan of care. Rationale According to Kozier textbook, involving the old aged pt in the plan of care enhances pts self-esteem. 2) The nurse will listen carefully to the pts concern each time of the nurses visit to the pt. Rationale Listening attentively to the pts concern will enhance the self-worth of the pt according to Kozier textbook. 3) The nurse will encourage the pt to stay connected with their memories such as recording an autobiography and story telling. Rationale These activities are doable within the pts physical limitations and according to Kozier textbook, engaging in these types of activities enhance the self-esteem of the old-aged pts. The nurse will encourage her to use her stronger part of the body for her self-care such as combing her hair during her shift. Rationale Accoding to Kozier textbook, reinforcing clients strength helps the client to adjust with the change and enhances self esteem. The nurse will teach the client to explore positive thought during the conversation period with the patient in her shift. Rationale Substituting negative thoughts with positive thoughts will help to rebuild the pts self-esteem according to Kozier textbook The nurse will provide the pt with honest and positive feedback after the completion of each self-care activity by the pt during her shift. Rationale According to Kozier textbook, honest and positive feedback is one of the strategies of acknowledging the limitation, focusing the strength by the patient therefore, it enhances patients self-esteem.