Patient able to communicate needs and concerns. No difficulty with communication noted.

1. The Humanbecoming Process Reflection
Student Name: Mariah Anne Lofgran
Date: November 17, 2014
Identify the skills you performed this week: Neurological assessment, cardiovascular assessment, respiratory
assessment, gastrointestinal assessment, transport patient to EEG (#3105), dressing change on another patient
(#3116), teaching patient on TPN and PCA (#3116).
Worth 100 points
Part I: Clinical Data Sheet- Demographic information; activities and orders; time management
organizational tool for planning care. Prepare in pre-clinical & use this tool to complete care.
(5 points)
Part II: Assessment Data- Laboratory Values, Medication Information (include TACTIS if
medication is administered), Review of Systems & Physical Assessment. (30 points).
Part III: Concept Map Flow Chart- Pathophysiology of Disease Process. Include risk factors,
signs & symptoms, medical treatments. Obtain information from textbook (15 points).
Part IV: Nursing Care Plan & Reflection- Answer questions & identify top 5 nursing
diagnostic statements. Complete template on highest priority physiologic & psycho-social
problem. Using the nursing process, record all steps of the nursing process including plans for
future care (50 points).
Student Grade: __________________
Corrected By: ____________________________
Comments:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
____

2. Part I: Clinical Data Sheet (5 points)
Student Mariah Lofgran Patient Initials L.V Gender Female Age 44 Room # 3109 Admit date 11/2/14
Client’s health priorities, including plans, concerns, needs: (possible questions- “What is most important or
the priority for the day and our time together?” “What is your hope regarding your situation?” “Would you like
some information, references, teaching, help etc?”” What needs do you have?””What does it mean to you to be
healthy?”)
-Patient expressed a hard time giving a definition of health, “it’s hard after having a double mastectomy and
having my encounter with breast cancer to be able to think about being healthy.”
Medical Diagnoses/ Surgeries (including dates; why is the client hospitalized?)
-Pyelonephritis, History of double mastectomy (April 2014) and left nephrectomy (1986).
Advanced Directive/Code Status Full code Ht. 5’1 Wt. 56.1 kg BMI 23.37 Precautions Standard
Allergies: Norco, Dilaudid, morphine, penicillin, Vicodin Occupation: N/A Comments: Unemployed
Oxygen: Room Air Diet: Cardiac Activity: Normal (Ambulatory)
Vital Signs (frequency & baseline): 123/62 T: 36.7 P: 75 R: 16 O2: 97%
Accucheck: N/A IV fluid: Normal Saline Rate: 125 ml/h Site: Left Forearm
Tubes/drains/dressing: N/A
Last 24 Hour Intake/ Output: 600ml/ 400ml Last BM: N/A
Multidisciplinary Care: Oncology, Pharmacy(need chemo meds), Other: N/A
Prioritized list of top 5 problems:
1. Acute Pain 3. Risk for Excess Fluid Volume 5. N/A
2. Disturbed Body Image 4. N/A
Organizational tool: Use to plan care for the day.
0700/1500: Receive Report 1100/1900: Lunch
0730/1530: Receive Report 1130/1930: Student Learning-Wound Care
0800/1600: Assessment 1200/2000: Student Learning-TPN/PCA
0830/1630: Assessment Continued 1230/2030: Patient Reassessment
0900/1700: Look up labs/Medications 1300/2100: Vital Signs
0930/1730: Take Patient to EEG 1330/2130: Patient Teaching-Body Image
1000/1800: Take Patient to EEG 1400/2200: Patient Teaching Continued
1030/1830: Document Pt info/ report to nurse 1430/2230: Final Assessment/ Warm Hand Off

3. Part II: Assessment Data (30 points)
Labs Normal ranges depend on the laboratory utilized. Lab values not included on this list should be included on next page.
Lab Reference Book Utilized: Pagana, K. D. & Pagana, T. J. (2009). Diagnostic and laboratory test reference (9th ed). St.
Louis: Mosby.
Test Range Admit value
w
i
t
h
d
a
t
e
1
1
/
2
Recent value
with date
N/A
Why was this test ordered and what is the significance
of the value?
WBC 5,000-10,000/mm3
6.5 N/A Monitor Bacterial Infection(No progression noted)
RBCs 4.2-6.1 x 106
/µg 3.88 N/A Monitor for Blood Clots while on Hypertensive Medications
Hgb 11.5-17.5 g/dl 12.5 N/A Monitor for Blood Clots while on Hypertensive Medications
Hct 40-52% 36.9 N/A Monitor for Blood Clots while on Hypertensive Medications
MCV 90-95 mm3
N/A N/A N/A
MCH 27-31 µg N/A N/A N/A
MCHC 32-36 g/dl N/A N/A N/A
RDW 11%-14.5% N/A N/A N/A
Retic. 0.5%-3.1% N/A N/A N/A
Platelet 150,000-400,000mm3
216,000 N/A N/A
Neutrophils 55-70% 48.5 N/A Monitor WBC count for infection and while on Chemo Meds
Lymphocytes 20-40% 40.1 N/A Monitor WBC count for infection and while on Chemo Meds
Monocytes 2-8% 9.6 N/A Monitor WBC count for infection and while on Chemo Meds
Eosinophils 1-4% 1.5 N/A Monitor WBC count for infection and while on Chemo Meds
Basophils 0.5-1.0% 0.3 N/A Monitor WBC count for infection and while on Chemo Meds
Sodium 135-145 mEq/L 140 N/A Monitor Fluids since patient doesn’t have a balanced I/O
Chloride 98-106 mEq/L 106 N/A Monitor Fluids since patient doesn’t have a balanced I/O
Potassium 3.5-5.0 mEq/L 37 N/A Monitor Fluids since patient doesn’t have a balanced I/O
CO2 24-30 mEq/L N/A N/A N/A
Magnesium 1.3-2.1 mEq/L N/A N/A N/A
Calcium 9.0-10.5 mg/dl 8.8 N/A Monitor for continued decrease while on Novadex
INR See lab result N/A N/A N/A
PT 11-12.5 seconds N/A N/A N/A
PTT
On anticoag. →
60-70 seconds
1.5-2.5 x control
N/A N/A N/A
BUN 10-20 mg/dl 10 N/A Monitor Kidney function following retention of fluids.
Creatinine 0.5-1.2 mg/dl 0.9 N/A Monitor Kidney function following retention of fluids.
Glucose 70-110 mg/dl 93 N/A Monitor glucose since patinet has decreased kidney function.
Hgb A1c 4.4-6.4% N/A N/A N/A
AST 0-35 U/L 20 N/A Monitor liver function while patient continues chemo
medication.

4. ALT 4-36 IU/L 26 N/A Monitor liver function while patient continues chemo
medication.
Acid Phos. 0.13-0.63 U/L N/A N/A N/A
Ammonia 80-110 µg/dl N/A N/A N/A
LDH 100-190 U/L N/A N/A N/A
Amylase 30-220 U/L N/A N/A N/A
Lipase 0-160 U/L N/A N/A N/A
Phosphorus 3-4.5 mg/dl N/A N/A N/A
Alk. Phos. 30-120 U/L N/A N/A N/A
Total Bilirubin .3-1.0 mg/dl N/A N/A N/A
Cholesterol <200 mg/dl N/A N/A N/A
Uric acid 2.7-8.5 mg/dl N/A N/A N/A
Total protein 6.4-8.3 g/dl N/A N/A N/A
Albumin 3.5-5.0 g/dl N/A N/A N/A
Globulin 2.3-3.4 g/dl N/A N/A N/A
Digoxin level 0.8- 2.0 ng/ml N/A N/A N/A
Theophylline level 10-20 µg/ml N/A N/A N/A
Dilantin level 10-20 µg/ml N/A N/A N/A
Additional Lab Values/ Diagnostic Test Results (X-ray results; nuclear medicine/CT/MRI, EKG etc.):
-RA Spine Lumbosacral 2/3 views- Pending
-Urinalysis-Pending
Medications: List all medications ordered (generic & trade names, classification, indication, dose, route,
time, & safe dose. Attach a “TACTIS” form for all administered medications. See last page for TACTIS.)
Generic name Trade name Classification Indication Dose Route Time Safe
Dose
Safe?
Yes/No
Benzapril Lotension Anti-
hypertensive
Management of
hypertension
10m
g=1t
ab
Oral daily 10mg
once
daily
Yes
Pantoprazole Proteonix Anti-ulcer
agent
Heartburn/GERD 40m
g=1e
ach
Oral daily 40mg
once
daily
Yes
Tamoxifin
citrate
Novadex Anti-
neoplastics
Adjuvant therapy
of breast cancer
20m
g=1t
ab
Oral daily 10-
20mg
twice
daily
Yes
Zolpidem Ambien Sedative Insomnia
difficulty sleeping
5mg
=1ta
b
Oral QHS
PRN
5mg
or up
to
10mg
Yes
Ondansetron Zofran Anti-emetics Prevention of
nausea and
vomiting
4mg
=2m
l
IV
Push
Q6H
PRN
4mg Yes
Ibuprofen Motrin Anti-pyretics Treatment of
fever/pain
600
mg=
1tab
Oral Q6H
PRN
400-
800mg
3-4X
Yes
Acetaminoph
en
Tylenol Extra
Strength
Anti-pyretics/
non-opioid
analgesics
Treatment of mild
pain/ fever
500
mg=
1tab
Oral Q6H
PRN
325-
650mg
q6h
Yes
Ciproflaxin Cipro Anti-infective Treatment of 200 IVPB E12 400mg Yes

5. 400mg/D5W bacterial infection mg H 7
days
Q12H
DATE/TIME OF PHYSICAL ASSESSMENT: November 3, 2014/ 0800
GENERAL APPEARANCE:
-Alert, oriented, calm in surroundings, a little tired and withdrawn.
Allergies: Norco, Dilaudid, morphine, penicillin, and Vicodin.
Code Status: Full Code
Isolation/Precautions: Transmission Based: Reason- ___________________________
Review of Systems: GENERAL
 Able to provide ROS  Unable to provide ROS
Cause: ___________________________________
 Significant other providing ROS
Name/Relation: ____________________________
 Fatigue  Difficulty sleeping  Low energy
 Change in appetite  Emotional distress
 Spiritual distress
Other concerns: ___________________________
Thin, Obese, Emaciated, Well-developed, Well-nourished, No Acute Distress (NAD)
Height: 5’1 Weight: 56.1 kg BMI: 23.3 Diet restrictions: cardiac
Admitting Vital Signs: 123/62 P: 75 O2: 97 R: 16 T: 36.7
O2 saturation: 97% Oxygen: Room Air
Pain level: 4 Location of pain: Abdomen Last Med: 0600
IVs, Tubes, Special equipment: IV Left Forearm
Normal Saline 125 ml/h
 Recent weight loss  Recent weight gain
 Concerns about weight
 History of hypertension  Recent fever
 History of heart palpitations “racing”
Pain: PQRST- Provokes/prevents: Movement
Quality- Sharp Radiates- N/A
Severity- 4 Timing- 2200
Other concerns: ___________________________
ACTIVITY:  Fall Precautions  Other Precautions ___________________________
Ambulation:  Independent  with assistance-  max  mod  min _____ persons
Assistive Device/s: Type ____________________________________________ N/A
Weight Bearing Status: FWB L PWB R PWB NWB  Bedrest 
Hemiplegia- side affected _______________  Paraplegia  Quadraplegia
Bathing/Hygiene/Dressing:  Independent  Assistance- type ____________________
Food/Nutrition:  Independent  Assistance- type ______________________________
 Change in basic ADLs in home (ex. walking,
eating, dressing, grooming)
ADL affected _____________________________
 Change in instrumental ADLs in home (ex.
shopping, house cleaning, driving)
ADL affected _____________________________
Other: ___________________________________
NEUROLOGICAL SYSTEM:
Level of Consciousness:
Awake Alert Oriented x ___ (time, place, person, event)
Restless Drowsy Sedated Confused
Precautions: Swallowing Seizure Spinal  Other ____________________
Glasgow Coma Scale: (Circle number that applies.)
a) Best eye opening: 4 Spontaneously 3 To Speech 2 To Pain 1 None
Review of Systems: NEUROLOGICAL
 Headache  Dizziness/Vertigo  Tremors
 History of Seizures  Dysphagia
 Weakness- location _______________________
 Incoordination Numbness/tingling
 History of head injury
 History of neurological problem/s
Describe _________________________________
 History of delirium: cause _________________
 History of dementia: type __________________
b) Best verbal response: 5 Oriented 4 Confused 3 Inappropriate words
2 Incomprehensible sounds 1 None
c) Best motor response: 6 Obeys commands 5 Localizes to pain 4 Withdraws
3 Flexion (decorticate) 2 Extension (decerebrate) 1 None
Total Glasgow Coma Scale ____ / 15 (Add a, b, c above)
Cranial nerves/Eyes/Ears: PERRL Pinpoint Fixed EOMS intact
Nystagmus Stribusmus Dilated, but reactive to light Dilated, nonreactive
Reflexes (physical examination):
Physical Assessment & Review of Systems

6. Unequal: R>L L>R Dolls eyes Other
Vision Deficits: Blind (legally) Glasses Contacts
Hearing Deficits: Deaf HOH  Hearing Aid(s): L R Bilat.
Romberg (+/-) ____ N/A ____
Reflex: (+/-) ____ N/A ____ cough ____ gag ____ corneal ____ Babinski
Other: __________________________________________________________________
Neurovascular: Extremities examined: Arms/ Legs
Color:  Pink  Reddened  Blue  Blanched
Movement: Active  Passive  Limited Temperature:  Cool  Warm  Hot
Sensation:
Intact Numbness Tingling Pain Absent
Other: ___________________________________
Communication:  Speaks English  No English  Primary language ____________
Verbal Writes notes Mouths words Nods head appropriately to yes/no
Other: ___________________________________________________________________
Country of Origin: United States
History of difficulty with communication:
_________________________________________
Emotions/Psychological State:  Suicide Precautions  DT Precautions
 Withdrawn  Depressed  Anxious  Fearful  Flat Affect  Euphoric
 Expressive Other: __________ Usual hours sleep: ________# Last 24 hours: _____
Restraints: N/A Type _______________ Reason: ____________________________
Check q _____ min/hrs  Remove/Replaced q ____ min/hrs Other: _________________
History of:  Danger to Self  Danger to Others
Self Mutilation Suicide Alcohol abuse
 Drug abuse  Depression  Anorexia Nervosa
 Bulimia  Insomnia
Other: _________________________
CIRCULATORY SYSTEM:
Heart Rate: 75 Rhythm: Normal Sinus
Heart Sounds: Describe: Regular S1, S2
Neck Veins (45o
angle): Flat Distended (Jugular Venous Distention)
BP: 125/65 R 127/63 L Apical Pulse: 76
Review of Systems: CIRCULATORY
 Chest pain/tightness  SOB  Orthopnea
 Cough  Fatigue  Cyanosis  Pallor
 Edema  Nocturia  History of hypertension
 High cholesterol  Murmur  Heart disease
 Smoking  Anemia  Obesity  Diabetes
 Rheumatic Heart Disease  Sedentary lifestyle
Other: ___________________________________
Capillary Refill: Brisk <3 sec. Prolonged >3 sec. _________ sec.
Nail bed Color: Pink Pale Cyanotic
Skin Color: Location: __________ Pink Pale Cyanosis Flushed
Jaundiced Mottled Pallor Circumoral cyanosis Other
Edema: Location: Arms/ Legs
None Generalized Non-pitting Pitting 1 + 2 + 3 + 4 + (circle)
Other
________________________________________________
Chest Pain: No Yes Describe__________________________________________
Pacemaker:  N/A  Permanent Type _______  Rate____ Location: _____________
Pulses (physical examination):
Homan’s sign: Left: pos. neg. Right: pos. neg.
Calf redness/tenderness: Left: yes no Right: yes no
Anti-embolism stockings: N/A Remove/Replaced q shift
Sequential compression device: N/A Remove/Replaced q shift
Other
IV placement; wounds/ incisions; tubes (see key)
Front palms up:
Intravenous Line/s
Solution Rate &/or dose (PCA/meds) Site clear/infiltrated/infected/other
-Normal Saline 125 mL/h Clear
Key for diagram:
IV - Intravenous PIC - Peripherally Inserted Catheter
PCA - Patient controlled analgesia SC - Subclavian Jug - Jugular
DI - Dressing dry & intact St - Staples clean & dry
F/C - Foley catheter SCD - Sequential Compression Device
NG - Nasogastric tube Stg 1-4 - Pressure sore; identify stage & size
D – Doppler
A – Absent
1+ - Barely Palpable
2+ - Weak
3+ - Normal
4+ - Full Bounding

7. Skin: Turgor: Location: Hands Elastic Tented Taut Shiny
Temp: Hot Warm Cool Dry Clammy Diaphoretic
Color: Location: Arms Pink Pale Cyanotic
Flushed Jaundiced Mottled Other
Bony Prominences: Skin Intact Reddened Gray
Pressure Sore Stage: _____ Location:
Other wound/incision location:
Healing/closure: N/A Sutures Staples Drain Dehiscence
Evisceration Healing by secondary intention Other
Dressing: N/A Dry/Intact Open to Air Stained Saturated
Changed: q _____ hrs Wet to Dry Other Describe:
Protocols: Braden Scale Special Bed Other
Mucous Membranes: Moist Dry Cracked Sores Patches
Pink Dusky Other
MUSCULOSKELETAL SYSTEM:
ROM: Active Passive CPM: Right Left N/A
Joints: Tenderness Pain Swelling No abnormalities
Traction/Cast: N/A Type: _______________ Joint/Extremity: _________________
Color: _____________ Sensation: ______________ Movement: _________________
Back of body:
RESPIRATORY SYSTEM:
Respiratory Rate: 16 Rhythm:  Regular  Irregular
Depth:  Deep  Shallow
 No distress  Dyspneic  Apneic ___ sec.
 Labored  Accessory muscle use  Tachypneic
Key: Breath Sounds
Cl - Clear D - Decreased
Cr – Crackles A – Absent Wh - Wheezing
Identify location of normal & adventitious
sounds:
Oxygen Therapy: RA FiO2 ___ L / or % NC Mask Trach Other
O2 Saturation: N/A q ___ hr Continuous pulse oximeter
Pulse Oximetry Readings (Identify on R.A. or O2): _______; _______; _______
Chest Config:  Symmetrical  Asymmetrical  Flail
Cough: No cough Weak Strong Frequent Infrequent
 Nonproductive  Productive Description: _________________________
Color _______ Odor ________ Viscosity ________ Incentive Spirometer
Shape of Chest: (circle) AP diameter 1:2 (nl), barrel, pectus excavatum/ carinatum
kyphosis, lordosis, scoliosis
Drainage: Chest Tube/ Pleuravac: R L Water seal only
Suction ____ cm of water N/A Other: _______________________________________
Review of Systems: RESPIRATORY
 SOB  Orthopnea  History of apnea
 History of asthma  History of emphysema 
History of smoking. Amount ___________
 History of other respiratory condition:
Type: _________________________________
 Proxysmal Nocturnal Dyspnea (PND)
 Cough  Productive  Non-productive
Other concerns/findings: History of Cough and
Shortness of Breath.
GASTROINTESTINAL SYSTEM:
Abdomen: Soft Firm Hard Tender Distended ____cm. Vomiting ___ccs
Bowel Sounds: Active Hyper Hypo Absent Flatus: Yes No
Review of Systems: GASTROINTESTINAL
Anorexia Nausea  Dysphagia
 Food intolerance: type: None
Result of intolerance: _______________________
Normal bowel habit: 1-2 BM daily
 Abdominal pain  Change in bowel habits
Describe: No Bowel Movement
 Blood in stool Last colonoscopy: __________
Normal diet habits:
_________________________________________
_________________________________________
_________________________________________
 Use of laxatives  Binging/Purging
Other: ___________________________________
Diet: Type_____________ NPO TPN Tube feeding Self-feed Assist-feed
 Swallowing precautions  Thicken liquids Dentures: Full Upper Lower
Meal: Breakfast Lunch Dinner % taken __________
Type gastric tube N/A Placement Verified
Purpose: Feeding Decompression Other
Formula: Type Rate cc’s q ___ hrs
N/A Suction: N/A Intermittent Low continuous
Drainage: Describe
Weight Loss: Amount __________ Time Period __________ N/A
24o
Intake ______ 24o
Output _______ Balance: Positive Negative
Blood Glucose Monitoring q _______ hrs Time/Result ________________ N/A
Stool: Formed Loose Impacted Last BM
Color: Regular Irregular
Outlet: Rectum Colostomy Ileostomy Rectal Tube Output: ______ cc’s
Stoma: N/A Pink Edema Dusky Surrounding Skin: D/I Excoriated

8. Toileting:Self Assist History Laxative Use: No Yes
Other/Descriptions: ________________________________________________________
GENITOURINARY SYSTEM:
GU Drainage: Voiding Straight Catheter q ___ hrs Indwelling Foley
3-way cath (irrigation) External cath Other _____________________________
Bladder Training Catheter Care Hourly Urine Output
Bladder Irrigation: Continuous Manual Solution:
Urine: Clear Cloudy Sediment Odor: Faint Offensive
Color: Light Yellow Dark Yellow Orange Clots Hematuria
Patterns: Incontinent Polyuria Nocturia Oliguria Urgency
Dysuria Retention Anuria Other __________________________________
Genitalia: No Anomalies Discharge Excoriation Other
Reproductive: LMP ___________ Premenopausal Postmenopausal Male
Hysterectomy: N/A Ovaries Removed Ovary/Ovaries Remain
Breasts: Symmetrical Asymmetrical Describe: ___________________________
Self Breast/Testicle Exams: Yes No Freq: _______________________________
Cancer Screen: Date _________ Test ________ Result _________________________
Date _______ Test ________ Result ________ (Breast, Pap, Prostate, Colon)
Sexual/Fertility Concerns: __________________________________________________
Review of Systems: GENITOURINARY
 Urinary frequency  Dysuria  Urgency
 Hesitancy  Straining  Nocturia
 Burning  Change in color, odor
Describe: Retention
Normal fluid intake pattern:
4-6 Glasses of water
Females:  vaginal itching  change in vaginal
discharge  History of female reproductive
problems  STDs
Describe: _____________________________
Males:  History of prostate/testicular or male
reproductive problems  STDs
Describe: _____________________________
Contraceptive Use:
Condoms, etc.
Part III: Concept Mapping: Pathophysiology Concepts (15 points)
Textbooks Utilized: Porth, C.M. & Matfin, G. (2014). Pathophysiology: Concepts of altered health states (9th
ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Instructions: Study your client’s disease process (medical diagnosis) and “map” the concepts of your client’s
condition as you see the concepts fit together. Include risk factors, expected signs/symptoms and medical
treatments as they relate to the pathophysiology of the disease process in your concept map. See Blackboard for
Template.

9. Part IV: Nursing Care Plan & Reflections (50 points)
Identify the nursing diagnostic statements for the top 5 problems you identified on your clinical data sheet.
Include at least one psycho-social problem & at least 1 “risk for.”
(Nursing diagnosis… related to… secondary to…).
1. Acute Pain related to pyelonephritis as evidenced by patient pain assessment at a level of 4.
2. Disturbed body image related to double mastectomy as evidenced by patient depression and sadness over loss
of her breasts.
3. Risk for excessive fluid volume related to pyelonephritis decreased kidney function.
In your own words, summarize your experience with your client.
- My client was very nice and she was very happy to have someone to talk to because her family wasn’t able to
come visit her yet since she had just got admitted to our floor. My patient was very open to allowing me to do
assessments and ask very deep questions concerning her diagnosis of breast cancer and the pain she was feeling
following her recent double mastectomy. It was a bit hard to get her to be cooperative once her family arrived
because she wanted to spend time with them.
Explain your emotional response to the patient assigned to receive your nursing care, identify emotions that
were surprising to you or anything that presented an ethical dilemma for you.
- I had a very strong emotional response to this patient because she very much like my grandmother is suffering
from the depression and low self-esteem that comes from having a double mastectomy. I struggled to keep calm
and not show how upset her story and how she was feeling made me. I took her story very personally and even
though it was a very difficult situation I felt that it gave me strength working with a patient that I had that stron
of a connection with.
Identify your strengths that were evident to you today as you cared for your assigned clients and list areas for
your continued growth.

10. - My strengths that I showed during the time working with my patient was my ability to place most of my deep
emotions to the side and be able to remain professional with my patient. Also my ability to still be
firm but respectful about working with my patient once her family arrived. Some areas that I feel
that I could still grow in are being able to more confidently answer my patient’s questions as well as
being able to identify more risk factors related to her diagnosis.
Part IV: Nursing Care Plan & Reflections (50 points) (continued)
Complete the chart for the most important physiologic (actual or “risk for”) problem related to your
client.Problem#1 (Physiologic): Acute Pain
Related to: Pyelonephritis

11. Defining Characteristics
Signs & symptoms (actual
diagnoses)
OR
Potential signs & symptoms (“risk
for” problem)
1. Facial grimacing when
being assessed.
2. Vocalizing pain of 4 out of
ten.
3. Being short of breath
when being touched.
Desired Nursing Outcome
Criteria
(reverse signs and symptoms OR
potential signs & symptoms; must
be measurable & specific)
Client will
1. Not shows facial signs of
pain within an hour of
pain medication being
administered.
2. Patient will have a pain
scale beneath 2 within 4
hours.
3. Patient will not be short of
breath from pain within
four hours.
Nursing Intervention Criteria (include rationale)
Include interventions related to assessment (always
first!); activities; medications (if applicable) and
teaching. Explain the purpose of the intervention (i.e.
rationale).
-Patient will be given ordered pain medication to
decrease pain level.
- Patient will be taught breathing techniques and
other distraction techniques like music or
television to help decrease the level of pain.
-Patient will take all ordered medication to treat
her pyelonephritis in order to help decrease the
pain level.
Evaluation of desired outcome
criteria
Was each of the desired outcomes
above met (i.e. the signs &
symptoms reversed)?
Client
1. Pain showed no facial
expressions of pain after a
half hour receiving pain
medication.
2. Patient expressed a pain
level of one after two hours
3. Patient showed no signs of
Shortness of Breath after
two hours of taking the pain
medication.
If the outcome criterion was not
met, what revisions in the plan of
care are needed?

12. Textbooks Utilized: Gordon, M. (2007). Manual of nursing diagnosis: Including all diagnostic categories
approved by the North American Nursing Diagnosis Association (11th ed.). Sudbury, Massachusetts: Jones and
Bartlett.
Part IV: Nursing Care Plan & Reflections (50 points) (continued)
Complete the chart for the most important psycho-social (actual or “risk for”) problem related to your client.
Problem #2 (Psycho-social): Disturbed Body Image
Related to: Double mastectomy Secondary to: Stage three Breast Cancer

13. Defining
Characteristics
Signs & symptoms
(actual diagnoses)
OR
Potential signs &
symptoms (“risk for”
problem)
1. Fears over loss of
breasts prior to
getting married.
2. Feeling less like a
woman without her
breasts.
3. Worry over new
husband seeing her
without her breasts.
Desired Nursing
Outcome Criteria
(reverse signs and
symptoms OR
potential signs &
symptoms; must be
measurable &
specific)
Client will
1. Express feelings
of contentedness
with body before
discharge.
2. Will express
feeling better as a
woman and ways to
view herself as more
than just her body.
3. Will express ways
of communicating
fears of her body
with her fiancé
before the wedding.
Reflection related to Nursing Interventions
1. Using concepts of Parse’s Humanbecoming
Theory describe an interaction where you were
truly present with your client or family member
regarding this nursing diagnosis.
-While discussing her breast cancer diagnosis she
asked if I had time to listen to how she was feeling
about the feelings she has regarding her cancer
because she was needing someone to talk too.
2. What were your client’s values, preferences,
expressed needs &/or hopes for the future & how
did you elicit them?
-My patient highly values the thoughts and
opinions of her fiancé and hopes that she can
come to terms with the way she feels about her
body so they can have a normal sex life.
3. Explain what actions you took to resolve
conflict, advocate for your client, &/or solicit input
from other health care team members.
-I spoke with my nurse many times about my
belief for her need to speak with someone in the
psychology department to have a safe and
experienced ear listen to her feelings about her
body and recommend ways of coping.
4. Identify other evidence-based nursing
interventions that relate to this nursing diagnosis if
applicable.
-I looked up the helpfulness of support groups and
locations of support groups to get an idea of how
helpful they may be and found that they are
considered very helpful for cancer patients and
recommended some to my patient.
Reflection related to Evaluation
1. What strategies allowed you to
successfully implement true presence
with your client?
-Sitting and speaking with my patient.
Making sure she knew that her priorities
for the day were my priorities for the day.
Asking clarifying questions and making
eye contact to express my interest.
2. What themes &/or patterns emerged
as you communicated with your client?
- A theme of fear and low self-esteem
over new found problems with her body.
3. What barriers did you struggle with?
- I struggled with not getting emotional
since I have a strong family connection to
breast cancer and the feelings that she is
feeling.
Evaluation of desired outcome criteria
Were each of the desired outcomes
above met (i.e. the signs & symptoms
reversed)?
Client
1. Patient expressed ways of coming to
terms with the loss of her breasts and
ways to continue to improve her view of
her body.
2. Patient expressed knowing that she as
a person is beautiful and the loss of her
breasts doesn’t change who she is but
that she is still trying to always remember
that.
3. Patients explained the idea of going to
family and premarital counselling to
discuss her fear of body image before
their wedding.
If the outcome criteria was not met, what
revisions in the plan of care are needed?

14. Textbooks Utilized: Gordon, M. (2007). Manual of nursing diagnosis: Including all diagnostic categories
approved by the North American Nursing Diagnosis Association (11th ed.). Sudbury, Massachusetts: Jones and
Bartlett.