Desired Outcomes

1. Infection
Patient will show no signs/symptoms of
infection at discharge

2. Impaired tissue integrity

Patients surgical incision will show no
evidence of infection or worsening
dehiscence by discharge

3. Impaired physical mobility

Patient will remain free of complications
of immobility as evidenced by intact
skin, absence of thrombophlebitis, and
clear breath sounds throughout this
admission.

4. Imbalance nutrition: less than

body requirements
Patient will consume at least 50% at
every meal.

5. Impaired airway

Interventions
1. Monitor lab values: WBCs, culture
results, urinalysis.
2. Monitor VS, especially temperature
3. Assess wounds for signs of infection.
4. Administer antibiotics (Flagyl, Cipro)
as ordered.
5. Perform foley/peri care
6. Assess lungs (crackles, sputum
changes), abdomen (distension,
pain/tenderness decreased bowel
sounds) and urine (cloudiness, foul
odor, swelling at foley site) for signs of
infection.
1. Assess condition of the wound and
condition of surrounding tissue.
2. Change wound dressing as needed.
3. Apply abdominal binder
4. Encourage intake of nutritious diet
5. Cleanse wound with alcohol
6. Assess body temperature for fever
(possible sign of infection
1. Assess ability to assist with
repositioning, transferring
2. Assess skin for evidence of pressure
ulcers
3. Apply SCDs while in bed.
4. Turn patient every two hours
5. Encourage and facilitate transfer to
chair
6. Encourage use of incentive
spirometry, Acapella device (patient
brought his own from home)
1. Monitor nutrition related labs:
albumin, protein, RBC count,
electrolytes
2. Monitor weight
3. Provide good oral hygiene
4. Ensure pleasant environment,
facilitate proper positioning, open
containers
5. Assess barriers to intake: poor
dentition, attitude towards eating,
dislike for hospital food.
6. Refer to dietitian (did not get to
perform this intervention)
1. Assess breath sounds, respiratory

clearance/ineffective breathing
pattern
Patient will maintain optimal breathing
pattern and clear open airways
throughout shift

6. Risk for unstable blood glucose

levels
Patient will maintain a blood glucose
level above 70 this shift and remain
free of signs/symptoms of
hypoglycemia.

7. Hopelessness
Patient will express positive
expectations about the future within 1
month.

rate, rhythm, depth, and effort.

2. Monitor oxygen saturation with pulse
oximetry.
3. Encourage coughing.
4. Provide suction to assist in clearing
secretions
5. Keep head of bed elevated.
6. Call respiratory therapist as
necessary for PRN breathing treatments
(primary RN did this)
1. Monitor blood glucose levels
2. Assess for signs of hypoglycemia
3. Assess eating patterns and other
nutritional intake (tube feeding, in this
case)
4. Administer insulin according to
sliding scale, withhold for BS below
prescribed level.
5. Encourage PO intake, especially of
carbohydrate containing foods since
patient is more at risk for hypoglycemia
than hyperglycemia right now.
6. Assess medications for drugs that
affect blood glucose
1. Assess for verbalizations of
hopelessness, lack of self-worth, giving
up, and suicide.
2. Provide patient opportunities to
express feelings of pessimism.
3. Convey feelings of acceptance and
understanding. Avoid false
reassurances.
4. Encourage the patient to reminisce
about the past.
5. Provide opportunities for the patient
to control the care environment.
6. Assist the patient in developing a
realistic appraisal of the situation.

Evaluation
1. Infection- Patient will show no signs/symptoms of infection at discharge
PARTIALLY MET- ONGOING

WBCs and neutrophils remain elevated, but trending downward. Patient remained
afebrile throughout shift. Other VS remained WNL, except for BP (elevated, but
patient with hx of chronic HTN). Received Flagyl and Cipro as ordered. Wounds
with serosanguinous drainage, no redness, pain, or warmth. Urine was amber, very
scant amount of blood noted (patient on warfarin, traumatic foley insertion). Initial
urinalysis suggested infection, but no further urinalysis performed since 11/3.
Lungs with audible wheezes, but no crackles. Abdomen distended, no guarding.
Patient denies pain, nausea, vomiting. Foley care performed.
2. Impaired tissue integrity- Patients surgical incision will show no evidence of
infection or worsening dehiscence by discharge.
PARTIALLY MET-ONGOING
Surgical site and j-tube with moderate serosanguinous drainage (more serous)
drainage than expected 9 days postop. No warmth, redness or pain. Staples intact
at midline incision, ostomy bag covering j-tube site. Midline incision dressing
changed, cleansed with alcohol, wound edges well approximated. Replaced
abdominal binder after removing for assessment and dressing change. Encouraged
PO intake, patient refused breakfast and ate only 25% of lunch. May require PO
supplements or enteral supplementation to provide protein and calories to promote
healing. Afebrile.
3. Impaired physical mobility- Patient will remain free of complications of
immobility as evidenced by intact skin, absence of thrombophlebitis, and clear
breath sounds throughout this admission.
PARTIALLY MET/ONGOING
Patient was able to use trapeze and assist with turning, repositioning, brief changes,
and transfers to chair. SCDs were applied when patient was in. Other than surgical
wound and j-tube, no evidence of skin breakdown. Spent a total of 90 minutes in
chair throughout shift. Patient was turned every 2 hours. Used Acapella vibratory
device, but not incentive spirometry. No evidence of DVT, or pressure wounds.
Lungs with audible wheezes in the morning before breathing treatment, no crackles.
4. Imbalance nutrition: less than body requirements- Patient will consume at
least 50% at every meal.
NOT MET
Patient did not have protein or albumin labs. Sodium, potassium, phosphorus and
calcium labs were low. RBC count low, but may also be low due to recent blood
losses from surgery versus poor nutritional status. Patient is ~90% of ideal body
weight. Provided oral care. Assisted in setting patient up for meals. Patient
verbalized that he was not hungry and ate plenty yesterday. Ill rest today, and eat
more tomorrow. Patient has dentures that fit well, and is able to feed himself.
Refused breakfast, and consumed only 25% at lunch. I did not get to do this, but
patient would benefit from a dietary consult.

5. Impaired airway clearance/ineffective breathing pattern- Patient will

maintain optimal breathing pattern and clear open airways throughout shift
MET
In the morning, patient had audible wheezing, was slightly tachypneic (24
breathes/min), increased effort of breathing. Patient denied shortness of breath, O2
saturation was 98% on room air. Primary RN called RT for breathing treatment,
which resulted in a decrease in wheezing the patient verbalizing that it was easier
to breathe. Head of bed remained elevated while patient was in bed. Patient had a
persistent wet cough and oral suctioning was kept within reach at all times so
patient could suction his own secretions. O2 saturations remained at 98% on room
air.
6. Risk for unstable blood glucose levels- Patient will maintain a blood glucose
level above 70 this shift and remain free of signs and symptoms of hypoglycemia.
MET
Patients fasting glucose in AM was 278, patient received 3 units of insulin lispro.
Patient refused breakfast. Tube feeding was discontinued at ~0900. Glucose level
at 1130 Accucheck was 99. Insulin was withheld according to sliding scale order.
Patient showed no signs or symptoms of hypoglycemia: no shakiness, diaphoresis,
fatigue, change in level of consciousness, headache or palpitations. Encouraged
carbohydrate at lunch, patient ate a total of 25% (some of which including peas and
rice- CHO sources). Patient was on Januvia until this shift, which was discontinued.
No other drugs with profound effects on blood sugar noted. Although patient was
asymptomatic and last glucose reading was normal, I would have felt more
comfortable rechecking his blood sugar around 1400 given his poor PO intake and
morning insulin administration.
7. Hopelessness- Patient will express positive expectations about the future
within 1 month.
PARTIALLY MET/ONGOING
Patient was irritated and at times uncooperative. Did not like being touched so
much. Verbalized that he felt it was time for him to die already and that all of the
medications and touching by the doctors and nurses was unnecessary. Did not
verbalized any suicidal ideations. Discussed how he felt like he was suffering every
day. Encouraged patient to share where he was from, where in turn he talked about
his successful restaurant business and former athletic endeavors, which he seemed
to enjoy. Reiterated to patient that he is getting healthier, pointed out that wound is
healing, he is in less pain, and he is no longer on tube feeding. Praised him for
agreeing to spend time in the chair.