Clinical Guide
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 meals as well as after eliminating wastes but still requires assistance in order to see. In regards to respiratory secretions, patient is able to handle on her own.

2. What is patient's temp? Was unable to read temperature because we were only provided with tympanic thermometers and client had hearing aides in both ears. I was advised to skip the procedure. WBC's? Lab results indicated a level of 5.9, which is within normal range.

3. Are skin and mucous membranes intact? None of the following were observed. Client's skin seemed to be soft and well moisturized. Did observe lentigo spots on the client's arm but other than that no other skin or mucous membrane issues were observed. Lesions Surgical Incision Decubitus Ulcer Redness or swelling IV's or other invasive linesTubes Catheters

4. Has culture and sensitivity been done on blood or secretions? What is result? Was unable to find any culture and sensitivity results in the client's chart.

5. Is patient subjected to an abnormal amount of stress? Patient seems to be quite content with herself as well as current living situation. She did not express any feelings of stress or discomfort. 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. F._

Assessment Category:__Bacteriological Safety _____ Room #_443 W_

In the space below, separate or cluster assessment data into assets (positive) or deficits (negative) regarding the client’s health status. Then write all appropriate nursing diagnoses in the Problem, Etiology, Signs/symptoms (PES) format that correspond with that data.

Assets: Client does not have any disease or condition that affects immunity. Does not currently take any medication that can affect immunity. She is very alert and cognitively aware. Listens and understands very well. Client is able to get around in her wheelchair. She is currently eating well and taking all prescribed supplements.

Deficits: Client needs assistance in order to get in and out of bed, as well as in and out of her wheelchair and to and from the bathroom as well as any other location outside of her room. Client is diagnosed with glaucoma and says she has serious trouble with her vision. She states she mostly sees blurs and her vision is rarely focused which can lead to inability to perceive body part or spatial relationship. Client relies mostly on her sense of hearing rather than her vision which can lead to impaired mobility status. Client is diagnosed with Alzheimer's Disease and senial dimentia which can lead to perceptual and cognitive impairment.

Nursing Diagnosis (es) Client is at risk for Self Care Deficit related to sensory impairment, in this case vision impairment, inability to perceive body part or spatial relationship as well as perceptual or cognitive impairment as manifested by inability to see people and things at near or far distances. Needs assistance to get from place to place and relies on assistance in order to perform most self-care activites.

Priorities would be to further assess extent of impairments and assist in finding ways or technique changes to meet self-care needs if ever necessary.