Assessing the Need for Bacteriologic Safety
This is a guide to assist you in performing a needs assessment on your client. You should ask yourself each question as you enter your client’s room and throughout your clinical day and write an answer. You should then write all appropriate nursing diagnoses in PES format.
l. Is patient able to maintain personal hygiene?
Bathing and Oral Care: Client is able to handle her own bathing and oral care with assistance and help from the aide. Client's vision is very minimal. As per her chart she has glaucoma and she stated that it is very difficult for her to see.
Client is aware of the necessity of Handwashing before ...view middle of the document...
As per an evaluation read in her chart, she seems to be doing well emotionally and as per the evaluation she is not currently at any risk for stress or depression. Although she does not participate much in morning social activities, she is very active in afternoon activities at the facility.
6. Is patient maintaining:
Nutritious diet? Amount taken?
Client eats breakfast, lunch and dinner and takes a boost supplement 2x a day. As per her aide she eats adequately and is also being prescribed multi-vitamins.
Adequate rest and sleep?
As per the client, she stated that she has been sleeping well lately and that she “Slept very well last night...” Her last progress note on 9/14/2010 stated there was a discontinuation of the medication Trazodone that was being given for insomnia, although Trazadone is also used to treat depression. As per her chart the medication was discontinued after an evaluation that concluded no depression signs were noted and that the client was now sleeping well and under normal circumstances.
7. Is patient receiving medication which affect immunity?
(Steroids, Antibiotics, etc)
The client is being prescribed medications for osteoporosis and glaucoma among
others, but none of them are listed as medications that affect immunity.
8. Does patient have disease or condition which affects immunity?
As per my assessment of the client and the information on her chart she does not
currently have any diseases or conditions that affect immunity.
Some possible Nursing Diagnoses derived from deficits in Bacteriologic Safety:
Self Care Deficit: Total
Self Care Deficit: Feeding, Bathing/hygiene, dressing/grooming, toileting
Impaired Oral Mucous Membranes
Impaired Skin Integrity: Actual /Potential
Ineffective Health Maintenance
Risk for imbalanced Body Temperature
Risk for Infection
Student Name:__Elizabeth Rosa ______________ Client Initials__F....