CLINICAL NURSING PROCESS FORM : SEATTLE CENTRAL COLLEGE: DATE:

NURS ______
PATIENT DATA NURSING ASSESSMENT BASE ACTUAL OBSERVATION
Pt initials: _RB___ Age: (CHART) PLANNED ASSESSMENT ASSESSMENT 1 ASSESSMENT 2
_78_ Cognitive-Perceptual Check pt for alert and T: 98.4 T: 98.0
Pattern: (Neurological) oriented, check pt is Alert and oriented x3. Alert and oriented x3.
M/F Ht: _F__ Pt is alert and oriented PERRLA, temperature, PERRLA. Pt is PERRLA. Pt is
Wt.:_202.8Lbs__ x3, facial expressions check pt can follow cooperative. Hand grasp cooperative and
BMI:___ are normal, tongue commands, cranial nerves strong and equal follows to command.
movement is normal for neuro assessment bilaterally. Able to do
Rm#: 209A Admit date: facial expressions
12/12/2024
Oxygenation-Exercise Auscultate heart sounds, BP: 105/58 BP: 110/62
Allergies : NKA Pattern: take BP, pulse rate, cap P: 89 P: 82
Code status: FULL (Cardiovascular) refill, peripheral pulses, BP normal,heart sounds 2+ pitting edema on
1 Medical Dx: Edema due to CKD, CHF extremity temp/perfusion, normal, cap refill 1s, 2+ both feet and legs, no
Hypertension as pt about chest pain, pitting edema on both pain or tenderness
2 Medical Dx: Chronic assess orthostatic feet and legs reported when
Kidney Disease stage hypotension palpating.
3A Activity-Exercise Auscultate lung sounds, R: 18 R: 18
Baseline vitals : Pattern: (Respiratory) ask about cough, SaO2: 99 SaO2: 98
date:_2/2/2025__ Normal and equal production of sputum, Lung sounds clearon Lung sounds normal
bilaterally lung sounds SOB, what causes SOB, both, cough and SOB and equal bilaterally.
T: 98.4 P: 89 R:18 take resp rate and saO2, reported
assess for orthopnea
BP: 105/58 O2:98 Pain: Nutritional-Metabolic Visualize and auscultate Normal, soft bowel Soft, normal bowel
3 Pattern: abdomen for bowel tones sounds in 4 quads. Skin sounds in 4 quads.
(Gastrointestinal) x4 quads, ask about soft and warm. Oral Incontinent in brief.
Diet: Regular limit CHO, Pt has constipation normal BM patterns, ask mucosa is pink and Abdomen is soft and
thin consistency for stool condition, moist. warm. Eat good 3
Activity/assistance: visualize oral mucosa, ask meals and snacks.
about normal eating
Surgery: No surgery habits
history Elimination Pattern: Ask for normal or/and any Pt has indwelling Pt reported feeling
(Genitourinary) abnormal urine output catheter. Normal output pressure in bladder
Precautions: None CKD stage 3A amount and color, pain is 800mL per shift and needed flush
report with normal
Events leading to color.
hospitalization: Nutritional-Metabolic Assess strength in the Able to move arms but Muscle weakness.
Pattern: extremities x4. has limit in moving Able to move all climb
(Musculoskeletal) lower extremities. but limit in lower
Relevant medical Mobility impairment due Report feeling tingling in extremities. Needs
history: to muscle weakness in lower extremities assistance to transfer
- Anxiety lower extremities. Able in/out of bed
- CKD stage 3A to move upper
 - Hyperlipidemia extremities and feed
- Chronic heart herself
failure
Nutritional-Metabolic Assess areas of skin Skin is warm but too Skin is too dry
Pattern: breakdown, ask about dry. Poor skin elasticity. moisture and skin
(Integumentary) itching, dryness, note No skin breakdown lotion applied
No skin issue or temp, moisture and
breakdown noted elasticity of skin.

Nutritional-Metabolic Ask about any endocrine CS: CS:

Pattern, Sexuality- conditions, ask about No concerns at this time No concerns at this
Reproductive Pattern: reproductive concerns. time
(Endocrine/Reproductive
)
No
endocrine/Reproductive
noticed at this time

Sleep-Rest Pattern: Assess for normal Sleep 10+ hours at Sleep throughout the
COMFORT/REST sleeping patterns, falling night and nap during night and often take
Pt sleeps 10+ hours a and staying asleep, daytime. No pain nap during day.
night and nap daytime assess pain level reported Bladder pressure
reported
TIME PLAN Role-Relationship ASSESSMENT 2 ASSESSMENT 2
Pattern
0700 Assist pt to get SELF-CONCEPT Record and report Pt is organized and Pt able to state what
her stuff for morning Pt has good self-concept behaviors that indicate oriented. Will call for she needs and how
hygiene adaptation to self-concept help when needed she feels

0800 Pass meds and ROLE PERFORMANCE Assess pt for her role Pt said she used to be a Pt is able to recall life
vital signs Able to provide function in her life. Ask teacher and she loves to events.
information about her about family support and draw and colors. She
0830 Breakfast role function. how changes in health loves walking her dog
status have affected around the
1000 Pt watches TV in ability to perform neighborhood but now
her room established roles she can’t walk herself
INTERDEPENDENCE Ask pt about her social Pt said she used to go to Pt wants to be alone
1100 Head to toe Pt is a Christian and relationship and any church and had a group and pray before meals
assess refers time to be alone social support groups that of friends there that
and pray she wants to participate share the same spiritual
1200 Lunch arrives, pt belief and lifestyle.
refers eggs salad
sandwiches

1330 Pt takes a nap

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RELEVANT LABORATORY VALUES
DATE TEST RESULT NORMAL SIGNIFICANCE
2/2/2 Creatine 2.01 0.76- High in creatine indicates kidney damage or disease. In this case pt has CKD
5 1.27
eGFR 39 Indicates kidneys are moderate to severe damaged, pt has CKD stage 3A
2/2/2 >90
5 RBC 3.62 RBC is low due to decreased in kidneys function. Could lead to anemia
4.7-6.1
2/2/2
5

PROBABLE NURSING DIAGNOSES PRIMARY NURSING DIAGNOSIS

- Anxiety/Depression Mobility impairment due to SOB, fatigue and weakness

- Skin integrity
- Constipation
- Fatigue/SOB PATIENT SHORT-TERM GOAL PATIENT LONG-TERM GOAL
- Muscle weakness/Impaired Achieve maximum functional independence in
Mobility Pt will improve current level of function in bed daily activities by utilizing assistive devices and
moblity , transter, eating, dressing, ADLs gradually increasing mobility levels within their
through PT, OT , ST, physical limitations, aiming to prevent further
decline and maintain quality of life
NURSING INTERVENTIONS RATIONALE/SOURCE EVALUATION OF EACH
INTERVENTION
Encourage Active and Passive Range of Motion Regular ROM exercises help prevent joint Cannot evaluate due to time period
(ROM) Exercises stiffness, muscle atrophy, and contractures,
maintaining flexibility and circulation.
Implement Fall Precautions (Call Bell Within Reach, Patients with impaired mobility are at a higher Cannot evaluate due to time period
Bed in Lowest Position, Non-Slip Socks) risk for falls, and safety measures help prevent
injury and ensure a secure environment.
Assistive devices help maintain mobility, Cannot evaluate due to time period
Provide Assistive Devices (Walker, Wheelchairs) prevent falls, and promote independence while
and assist pt when needed to transfer reducing strain on weakened muscles
Reposition the Patient Every 2 Hours Frequent repositioning prevents pressure Cannot evaluate due to time period
injuries, promotes circulation, and reduces the
risk of skin breakdown and deep vein
thrombosis (DVT).

TEACHING NEEDS & DC PLANNING EVALUATION OF SHORT TERM GOAL

- Teach the patient how to safely use walkers, canes, crutches, Cannot evaluate due to time period
or wheelchairs to prevent falls and ensure mobility
EVALUATION OF LONG TERM GOAL
- Advise on removing trip hazards (e.g., loose rugs, clutter), Cannot evaluate due to time period
installing grab bars in bathrooms, and ensuring adequate
lighting
- Encourage the patient to perform prescribed physical therapy
exercises or engage in safe activities to maintain strength and
circulation.
- Teach repositioning techniques for bed-bound patients and
the importance of keeping skin clean and dry.
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PATHOPHYSIOLOGY
PRIMARY DIAGNOSIS SECONDARY DIAGNOSIS
Hypertension Chronic Kidney Disease

The pathophysiology of hypertension involves the impairment of renal

pressure natriuresis, the feedback system in which high blood pressure Chronic kidney disease (CKD) is characterized by the presence
induces an increase in sodium and water excretion by the kidney that of kidney damage or an estimated glomerular filtration rate
leads to a reduction of the blood pressure. Pressure natriuresis can result (eGFR) of less than 60 mL/min/1.73 m², persisting for 3 months
from impaired renal function, inappropriate activation of hormones that or more. CKD involves a progressive loss of kidney function,
regulate salt and water excretion by the kidney (such as those in the often leading to the need for renal replacement therapy, such
renin-angiotensin-aldosterone system), or excessive activation of the as dialysis or transplantation. The 2012 KDIGO CKD
sympathetic nervous system. classification considers the underlying cause and categorizes
CKD into 6 stages of progression and 3 stages of proteinuria
based on glomerular filtration rate and levels of albuminuria.
Although the causes of CKD vary, certain disease processes
exhibit similar patterns.
The implications of CKD are extensive—it emerges from various
disease processes and affects cardiovascular health, cognitive
function, bone metabolism, anemia, blood pressure, and many
other health indicators. Early recognition of CKD is the first step
in treating it, and various methods for measuring eGFR have
been described. Both modifiable and non-modifiable risk factors
influence the progression of CKD. Management of CKD involves
adjusting medication dosages according to the patient's eGFR,
preparing for renal replacement therapies, and addressing
reversible causes to slow disease progression. This activity
reviews the etiology, evaluation, and management of CKD,
emphasizing the crucial role of an interprofessional healthcare
team in providing comprehensive care. An interprofessional
approach focuses on both modifiable and non-modifiable risk
factors to manage and mitigate the progression of the disease.

Source: https://accessmedicine.mhmedical.com/content.aspx? Source: https://www.ncbi.nlm.nih.gov/books/NBK535404/

bookid=2046&sectionid=176572779
NARRATIVE NOTES/ISBAR
ASSESSMENT 1 ASSESSMENT 2
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MEDICATION LIST
TIM DRUG NAME NORMAL DRUG ACTION SPECIFIC RATIONALE SIDE EFFECTS NURSING
E ORDERED DOSE, DOSE FOR PT RESPONSIBILITIES
DUE FREQUENCY & ROUTE
080 Metoprolol 100mg PO 50-100mg Beta blockers, works by Hypertension Headache , Monitor BP, ECG, and
0 relaxing blood vessels dizziness, pulse frequently during
and slowing heart rate to diarrhea, dose adjustment and
improve blood flow and dyspnea periodically during
decrease blood pressure therapy

Torsemide 20mg PO Torasemide (torsemide) Diuretic for edema,

080 BID is a high-ceiling loop water retention, Polyuri, Monitor neuromuscular
0 diuretic which acts on hypertension dehydration, signs of fluid and
the thick ascending limb dizziness. electrolyte
of the loop of Henle to imbalances(hypocalce
promote rapid and mia, hypokalemia,
marked excretion of hyponatremia,
water, sodium and hypovolemia,
chloride. Like furosemide hypomagnesemia)
(frusemide), its major
site of action is from the
2.5-5mg luminal side of the cell
Isosorbide Hypertension Monitor BP for signs of
080 mononitrate 30mg relaxing the blood Headache, hypotension, do not
0 vessels and increasing dizziness, crush or chew tab,
the supply of blood and nausea, flushing educate pt not taking
oxygen to the heart face any alcohol
while reducing its
workload