Chelsea Poligratis

NURS 360
Mini Care Plans
Expected
(complete before assessment)

Found
(complete after assessment)

Nursing
Diagnoses
(NANDA)

1. Acute pain related to right femoral 1. Risk for further injury and falls related
neck fracture and ORIF surgery
to right sided weakness; postural
AEB post-op day 3
hypotension associated with
2. Impaired physical mobility related
antihypertensive meds and analgesics
to bedridden and right femoral
and hypoglycemic episode, partial
neck fracture
weight bearing, and difficulty with
3. Risk for injury and falls related to
transfer and ambulation techniques.
right sided weakness due to prior 2. Impaired physical mobility related to
CVA, age-related osteoporosis
pain and weakness in weight-bearing
with pathological hip fracture, and
extremity associated with the fracture
partial weight bearing of affected
and subsequent surgical repair, and
RLE
prescribed activity and weight-bearing
4. Risk for ineffective tissue
restrictions.
perfusion related to post-op day 3 3. Acute pain related to tissue trauma
and reflex muscle spasms associated
with the initial injury, surgery, and
strain on the area postoperatively.

Focus of
physical
assessment

Pt age, VS especially BP (for

possibility of orthostatic
hypotension), blood glucose level,
LOC, cognitive and thought process
level, hearing and sight abilities,
level of balance and coordination,
degree of injury, ROM, pain scale,
elimination patterns, weight and BMI.
Also, muscular strength and agility,
fall risk assessment

Pt age, VS especially BP (for possibility of

orthostatic hypotension), blood glucose
level, LOC, cognitive and thought process
level, hearing and sight abilities, level of
balance and coordination, degree of
injury, ROM, pain scale, elimination
patterns, weight and BMI. Also, muscular
strength and agility, fall risk assessment

Need more
information
from
patient/famil
y/
doctor about:

Discharge plan needs addressed with

social worker and MD

Addressed discharge needs with social

worker and MD regarding continued
physical therapy and medications, followup appointments, any medical equipment
needed for home use, referrals for home
care or SNF

Top three
priorities
(goals) for
patient care

1.
2.
3.

1. Safety related to impaired physical

mobility - prevent further injury and
falls
2. Safety related to low BP and
hypoglycemia
3. Monitor and evaluate pain
4. Bowel and bladder elimination related
to immobility

Safety - prevent falls and injury

Monitor and alleviate pain
Tissue perfusion

Nursing
Interventions

1. Create protective environment

and ensure side rails up and bed
to lowest position.
2. Maintain immobilization of
affected leg, support fracture site
and joints while moving.
3. Evaluate reports of pain and
administer scheduled tylenol and
PRN pain meds as ordered.
Encourage relaxation techniques
like CDB.
4. Assist with safe ambulation within
limitations of weight-bearing
prescription and PT/OT exercises
regarding transfer and ambulation
techniques and use of front wheel
walker.
5. Perform neurovascular
assessment (CMS checks)

1. Maintain safe environment by

ensuring side rails up, bed to lowest
position, clutter-free room and
pathway to bathroom.
2. Contact guard assist during transfers
and ambulation using safe and proper
body mechanics and techniques with
use of front wheel walker within PWB
limitations.
3. Maintain immobilization and support
of affected extremity while moving
and transferring.
4. Ensure pt will eat meal prior to
administering rapid-acting insulin to
prevent hypoglycemic episode.
Monitor LOC.
5. Assess vital signs especially BP prior
to med administration.
6. Evaluate reports of pain and
administer scheduled tylenol and PRN
pain meds as ordered. Encourage
relaxation techniques like CDB.
7. Perform neurovascular assessment
(CMS checks).
8. Assess and evaluate bowel and
bladder elimination patterns.
Administered laxative as ordered.
Encouraged early ambulation.

Teaching
needed/provi
ded

Rapid-acting insulin administration

according to ISS before meals and at
bedtime, cardiac/consistent CHO diet
prescription, importance of early
ambulation and isometric and
flexion/extension exercises within
PWB order, SCDs and enoxaparin
injection for DVT prophylaxis, provide
education about osteoporosis and
necessary calcium + vit D
supplements

Rapid-acting insulin administration

according to ISS before meals and at
bedtime, cardiac/consistent CHO diet
prescription, importance of early
ambulation and isometric and
flexion/extension exercises within PWB
order, SCDs and enoxaparin injection for
DVT prophylaxis, provide education about
osteoporosis and necessary calcium + vit
D supplements

Discharge
planning

Medication education on
administration and side effects,
anticipate SNF for STR vs home with
DME: FWW,

Referral for physical therapy and

placement in SNF, medication
reconciliation, awaiting front wheel
walker for home use, new order to
administer NS 500 ml IV bolus to ensure
pt BP stable prior to discharge.

Expected
(complete before assessment)

Found
(complete after assessment)

Nursing
Diagnoses
(NANDA)

1. Ineffective breathing pattern related to

1. Impaired tissue integrity related to wound care
impairment of innervation of diaphragm as C3status as evidenced by immobility; wounds on left
C7 contusion spinal cord injury as evidenced by
hip, midback, left thigh donor site; skin tear on left
PEG tube placed due to dysphagia evaluation,
shoulder and midback; open scalp wound; bedrest
2L nasal cannula, use of accessory muscles, and
order; altered peripheral circulation and sensation
oropharyngeal suctioning as needed.
as tingling to upper extremities; presence of edema
2. Impaired tissue integrity related to wound care
to lower extremities.
status as evidenced by immobility, bedrest
2. Acute pain related to trauma and wound care. as
order, altered peripheral circulation and
evidenced by patient reports increased pain during
sensation, presence of edema.
wound care and repositioning, oxycodone IR tab
3. Acute pain related to trauma and wound care. as
q4h PRN, IV PF or IVP fentanyl qh per wound vac
evidenced by patient reports increased pain
dressing changes, muscle spasms, immobility.
during wound care and repositioning,
3. Impaired urinary elimination related to disruption
oxycodone IR tab q4h PRN, IV PF or IVP
in bladder innervation as evidenced by cervical
fentanyl qh per wound vac dressing changes,
spinal cord injury, voiding incontinence, bladder
muscle spasms, immobility.
scan q3h with straight catheter if amount > 400 ml
to foley catheter insertion.

Focus of
physical
assessmen
t

Respiratory assessment (pulse oximetry, RR, use of

accessory muscles, O2), skin assessment (cap refill,
redness, swelling, pulses, hygiene), wound
assessment and status (monitor wound vacs), pain
assessment (pain level, last PRN med, location and
intensity, alleviating and aggravating factors)

Respiratory assessment, motor function

and tolerance, CMS checks, skin
assessment, wound location and
assessment on wound vac status and
dressing changes as ordered, pain
assessment, intake and output, safety
checks, lines/drains/tubes, hemodynamics,
vital signs, GI/GU assessment

Need more
information
from
patient/fa
mily/
doctor
about:

Respiratory status, verbal or nonverbal

pt?, PT/OT referrals, social history, history
of present illness, family support,
discharge plans, wound status, medical
status

Pt decannulated thus fully verbal, swallow

evaluation, PT/OT sessions held as ordered
by MD due to wound vacs removed, able to
gain pertinent information on events that
led to admission, current social support, pt
able to ask his healthcare team questions
regarding his care

Top three
priorities
(goals) for
patient
care

1. Maintain adequate ventilation and lung function

2. Cardiovascular management
3. Pain management

1. Wound care/pain management

2. Urinary elimination
3. Tube feeding

Nursing
Interventio
ns

1. Closely monitor pt RR, depth, pattern. Monitor

breath sounds, cough strength and effectiveness,
maintain continuous pulse oximetry, maintain
HOB elevation.
2. Routinely inspect pt skin, use Braden scale.
Turn pt q2h. Avoid contact of bony
prominences. Use specialty bed. Provide
adequate nutrition of Jevity 1.2 cal bolus GT
feedings.
3. Identify and rate pain. Evaluate increased
irritability, precipitating factors. Provide
comfort measures like repositioning, massage,
ROM exercises. Encourage CDB. Administer
medications as ordered (PRN pain meds,
muscle relaxants).

Teaching
needed/pro Spasticity management
vided

1. Assessed and monitored pain. Administered pain

meds as ordered prior to removal of x3 wound
vacs. Assessed and monitored status of wound
dressings on left ischium, midback, and left thigh
donor site. Dressings remained intact.
2. Skin tears on left shoulder and left back assessed,
cleansed with NS, patted dry, applied honey gel,
covered with mepilex dressings. Wound beds
pink, dressings remain intact.
3. Open scalp wound assessed, cleansed with NS,
applied vaseline/bacitracin to keep moist. Sutures
removed, healing well.
4. GT site dressing assessed and changed as ordered.
No s/s of infection noted. Dressing remains intact.
5. Pt was on bladder scans q3h with straight cath if
total amount > 400 ml. Subsequently, pt got foley
catheter inserted due to urinary retention.
Monitored for adequate urine output levels and
void characteristics. Pt continues on bolus GT
feedings, tolerating feeds and meds well.
6. Administered 310 ml bolus tube feedings Jevity
1.2 cal as scheduled. No residuals prior to
feedings, no N/V noted, tolerating feeding well,
aspiration precautions. Bowel sounds present,
round abdomen, soft, non-distended, non-tender.

Temperature dysregulation

Skin care

Resume PT/OT as appropriate

Autonomic dysreflexia

Bowel, bladder function

Musculoskeletal issues

Medication education

Pain management
Discharge
planning

SNF placement?
Rehab program placement - location on
Oahu or Oregon due to girlfriend in Oregon

Expected
(complete before assessment)

Found
(complete after assessment)

Nursing
Diagnoses
(NANDA)

1. Infection related to group A

streptococcus bacteremia as
evidenced by necrotizing soft tissue
infection of right leg and fungal
infection to abdomen and groin
creases and under breasts.
2. Acute pain related to inflammatory
response of subcutaneous tissue.
3. Ineffective tissue perfusion related to
peripheral edema to bilateral lower
extremities, negative CMS.

1. Ineffective peripheral tissue perfusion

related to inflammatory response
secondary to cellulitis as evidenced by 3+
pitting edema to bilateral lower
extremities, pt reports decreased sensation
and numbness secondary to history of
right lower extremity edema, non-ST
elevation myocardial infarction, venous
insufficiency, and type 2 diabetes mellitus.
2. Impaired tissue integrity related to
damaged skin secondary to group A
streptococcus bacteria secondary to
history of chronic left lower extremity ulcer
as evidenced by non-intact skin and wound
care status.
3. Acute pain related to local inflammatory
response of subcutaneous tissue as
evidenced by patient vocalizing 9 out of 10
sharp and aching pain to right leg and
breast and increased pain upon moving
and sitting in therapy chair, facial
grimacing, guarding, and screaming.

Focus of
physical
assessment

Skin/wound assessment, pain level, CMS

checks, wound vac, baseline vital signs
compared with current vital signs, motor
function, LOC, bowel and bladder
elimination patterns, wound care status

Skin/wounds assessments, lines/drains/tubes

(wound vac, PICC IV access, foley catheter),
I/O, VS, CMS, motor function, LOC, mental
status, bowel and bladder elimination
patterns, pain levels, wound care status

Need more
information
from
patient/family/
doctor about:

Family support, living situation

Self-care ability to perform ADLs, family

support, financial support, living situation,
safe placement after discharge

Top three
priorities
(goals) for
patient care

1. Infection
2. Pain management
3. Ineffective tissue perfusion

1. Tissue perfusion/hemodynamics/low H&H

2. Skin/wound care
3. Pain management

Nursing
Interventions

1. Adhere to contact isolation

1. Perform vascular assessment (CMS
precautions to avoid further infection
checks). Keep right lower extremity
by wearing PPE. Administer IV
elevated above heart using two pillows.
antibiotic as prescribed. Maintain
Administer diuretic as prescribed. Monitor
aseptic technique when performing
I/O. Monitor H/H lab values as low values
wound care and dressing changes.
may be related to bleeding from wounds.
Apply antifungal cream to affected
Encourage PT participation to promote
areas.
2. Assess/monitor skin and wound status.
2. Assess/monitor pain level. Bed rest as
Perform wound care as ordered. Provide
necessary. Administer pain
skin comfort like applying lotion to reduce
medication as needed., monitor
skin dryness and flaking and ease
effects (respiratory status, bowel
discomfort. Apply antifungal cream to
elimination patterns).
abdomen and groin creases and under
3. Perform vascular assessment (CMS
breasts.
checks). Monitor/assess for acute
3. Assess/monitor pain level. Bed rest as
changes. Maintaining elevation of
necessary. Administer pain medication as
affected leg above heart is essential.
needed., monitor effects (respiratory
Administer diuretic as prescribed.
status, bowel elimination patterns).
Monitor I/O.

Teaching
needed/provid
ed

Instruct in cellulitis the importance of

elevation and immobilization of the
affected limb to reduce swelling. Proper
instruction to wound care and dressing
changes. Advise how to apply cool
compresses for discomfort, alternating
with a warm compress or warm soak to
increase circulation to the affected area.

Preventing cellulitis by not sharing personal

items, cleaning equipment, washing hands
often, pressure stockings if recommended.
Self-care education such as elevating affected
leg above level heart to decrease swelling and
pain using pillows, and wound care and
dressing changes. Taking medication as
prescribed. Learning and performing safe and
appropriate PT/OT techniques.

Discharge
planning

Taking medications as directed, safe

techniques for physical and occupational
exercises in order to perform ADLs, ways
to prevent further infection and damage
to skin

Home care: taking prescribed antibiotics as

directed, keeping infected area clean, raising
affected area elevated above heart. Safe
PT/OT techniques to perform ADLs. Appoint
with social work to discuss safe placement
after discharge.

Expected
(complete before assessment)

Found
(complete after assessment)

Nursing
Diagnoses
(NANDA)

1. Ineffective breathing pattern related

to decreased lung expansion
secondary to motor vehicle collision
as evidenced by rib fractures and
pneumothorax.
2. Impaired physical mobility related to
accident injuries as evidenced by rib
fractures, nasal bone fracture, dental
trauma, left acetabulum fracture,
splenic and kidney laceration, and
non-weight bearing of right upper
extremity.
3. Ineffective tissue perfusion related to
injury process and dependence on
chest drainage system.

1. Impaired gas exchange related to

decreased oxygen diffusion capacity,
musculoskeletal impairment, pain/anxiety,
and inflammatory process as evidenced by
patient receiving oxygen via nasal cannula
with orders to wean as to maintain oxygen
saturation > 95%, continuous pulse
oximetry, use of accessory muscles, pain
to chest tube site, and activity
intolerance/fatigue during physical activity.
2. Altered bowel elimination patterns related
to patient has had no bowel movement
since admission (10/11).
3. Risk for trauma related to injury process,
dependence on bilateral chest tube
drainage system to water seal, lack of
safety education/precautions.
4. Acute pain related to physical injuries and
patient on chest drainage system.

Focus of
physical
assessment

Baseline and current VS, respiratory

assessment, motor function, mental
status, LOC, bowel and bladder
elimination patterns (I/O), CMS check of
right forearm, pain levels, check chest
drainage, check IV access

Baseline and current VS, respiratory

assessment, motor function, mental status,
LOC, bowel and bladder elimination patterns
(I/O), CMS check of right forearm, pain levels,
check chest drainage, check IV access

Need more
information
from
patient/family/
doctor about:

Any family or social support, living

situation, financial concerns, safe and
appropriate rehab or SNF placement after
discharge, assess self-care ability

Social work consult, PT/rehab placement,

shelter placement after discharge,
financial/insurance concerns, self-care ability

Top three
priorities
(goals) for
patient care

1. Promote/maintain lung re-expansion

for adequate oxygenation/ventilation.
2. Minimize/prevent complications.
3. Reduce discomfort/pain.
4. Provide information about disease
process, treatment regimen, and
prognosis.

1. Promote/maintain lung re-expansion for

adequate oxygenation/ventilation.
2. Treat constipation/monitor bowel
elimination patterns.
3. Prevent trauma and complications.
4. Pain management

Nursing
Interventions

1. Assess breath sounds. Observe for

signs of respiratory distress. Maintain
continuous pulse oximetry, monitor
oxygenation status closely.
Administer oxygen via nasal cannula
as prescribed. Position the client in
high fowlers position. Provide oral
suction as needed.
2. Maintain/monitor chest tube drainage
system. Assess chest tube dressing.
Monitor/assess drainage amount and
characteristics.
3. Assist with splinting painful area when
coughing and deep breathing.
Maintain position of comfort with HOB
elevated. Encourage patient to sit up
as much as possible.

1. Assess breath sounds. Observe for signs of

respiratory distress. Maintain continuous
pulse oximetry, monitor oxygenation
status closely. Administer oxygen via nasal
cannula as prescribed. Wean oxygen as
appropriate to maintain oxygen saturation
> 95%. Position the client in high fowlers
position. Provide oral suction as needed.
Encourage use of incentive spirometer.
2. Assess GI system (abdominal
characteristics, presence of flatus, last BM,
stool). Monitor bowel elimination pattern.
Encourage food and fluid intake.
Encourage ambulation and participation in
PT/OT exercises.
3. Maintain/monitor chest tube drainage
system. Assess chest tube dressing.
Monitor/assess drainage amount and
characteristics.
4. Assess pain levels. Assist with splinting
painful area when coughing and deep
breathing. Maintain position of comfort
with HOB elevated. Encourage patient to
sit up as much as possible. Administer
scheduled and PRN pain meds as ordered.

Teaching
needed/provid
ed

How to use incentive spirometer, proper

cough and deep breathing techniques,
safe and appropriate PT/OT exercises,
medication education, non-weight
bearing of right forearm, preventing
complications with chest drainage system

Elevate right forearm with two pillows

maintaining non-weight bearing order, keep
left acetabular fracture straight, importance of
HOB elevated and using intermittent
compression devices in bed, importance of
incentive spirometer use for optimal lung
expansion, medication education, healthy diet
choices and reasons for constipation and ways
to promote healthy elimination patterns

Discharge
planning

Adequate ventilation/oxygenation
maintained. Complications
prevented/resolved. Pain
absent/controlled. Disease
process/prognosis and therapy needs
understood. Plan in place to meet needs
after discharge.

Patient will verbalize understanding of disease

process/prognosis and discharge planning
needs. Patient will have regained
independent lung expansion without chest
tube drainage system. Medications prescribed
upon discharge as directed. Social work
consult to discuss financial/insurance issues,
rehab placement, safe living/shelter
placement.

Expected
(complete before assessment)

Found
(complete after assessment)

Nursing
Diagnoses
(NANDA)

1. Infection related to MSSA left knee

1. Peripheral neurovascular dysfunction
prosthetic joint infection.
related to orthopedic surgery as
2. Ineffective tissue perfusion related
evidenced by immobilization of left leg
to immobilization of left leg, pitting
elevated with two pillows and 2+ pitting
pedal edema.
pedal edema to left foot and ankle.
3. Acute pain related inflammatory
2. Infection related to MSSA left knee
response of subcutaneous tissue and
prosthetic joint infection.
skin necrosis, and left leg wound
3. Acute pain related to local inflammatory
healing in continuous immobilizer
response of subcutaneous tissue as
and left anterior and lateral thigh
evidenced by patient vocalizing 4 out of
donor sites.
10 constant aching pain to affected leg,
patient stating it feels like a balloon
expanding because of the pressure,
PRN oxycodone IR tab q4h.

Focus of
physical
assessment

Skin/wound assessment, pain level,

CMS checks, PICC line assessment,
baseline vital signs compared with
current vital signs, motor function, LOC,
bowel and bladder elimination patterns,
wound care status

Skin/wounds assessments, I/O, VS, CMS,

motor function, LOC, mental status, bowel
and bladder elimination patterns, pain
levels, wound care status

Need more
Family support, living situation, PT/OT,
information discharge needs, self-care ability
from
patient/fami
ly/
doctor
about:

Resume PT/OT - how long will activity

restriction and immobilization of leg be?
Patient has been on bedrest all week
Patient able to perform ADLs independently
with assistance of using bed pan, able to
perform ROM exercises, and self reposition.
Patient and husband live on Big Island,
husband as support, has three children that
live in mainland.

Top three
priorities
(goals) for
patient care

1.
2.
3.
4.
5.

1.
2.
3.
4.

Infection
Tissue perfusion
Pain management
Immobilization of affected leg

Nursing
1. Promote good hand washing. Use
Intervention
strict aseptic techniques if needing
s
to reinforce dressings and handling
dressing with immobilizer on left leg.
Administer IV antibiotic piggyback
q4h as prescribed. Assess skin
color, temp, and integrity; note
presence of erythema or
inflammation, loss of wound
approximation. Monitor
temperature. Encourage fluid
intake.
2. Perform vascular assessment (CMS
check of left leg). Monitor for acute
changes. Maintain elevation of left
leg using pillows. Monitor I/O.
Maintain sequential compression
device on right leg.
3. Monitor pain level. Bed rest as
ordered. Administer pain medication
PRN oxycodone IR tab q4h as
needed., monitor effects (med
effective?, respiratory status, bowel

Tissue perfusion
Infection
Safety/comfort
Pain management
Immobilization of leg

1. Perform vascular assessment (CMS

checks). Keep right lower extremity
elevated above heart using two pillows.
Encourage fluids. Monitor I/O. Monitor
H/H lab values as low values may be
related to bleeding from wounds.
Encourage PT participation to promote
2. Maintain aseptic technique when
assessing and assisting patient due to
left anterior donor site open to air and
lateral thigh skin graft with xeroform. IV
antibiotic as ordered. Monitor temp.
3. Keep patient safe by having call light in
reach, bed to lowest position. Discussed
non-pharmacologic ways to relieve pain
and discomfort like listening to music
and deep breathing. Utilize pillows,
frequent repositioning to prevent skin
breakdown.
4. Assess/monitor pain level. Bed rest as
ordered. Administer pain medication as
needed, monitor effects (pain level
follow-up, respiratory status, bowel

elimination patterns).
4. Maintain left leg straightly aligned in
continuous immobilizer. Assist and
support with turning and
repositioning. Encourage ROM
exercises to unaffected joints.

elimination patterns).
5. Encourage patient to maintain
immobilization of affected leg and to not
allow leg to rotate internally to provide
for stabilization of prosthesis and reduce
risk for injury.

Teaching
needed/pro
vided

Inform patient of PRN pain med

schedule to relieve pain at constant
level. Instruct about importance of
maintaining immobilization, elevation,
and external rotation of affected leg.
Taking medications as directed.

Importance of maintaining immobilization

and elevation of affected leg, how to care
for wounds, looking forward - safe and
appropriate ambulation and PT/OT
techniques, partial weight bearing?,
increase protein in diet to promote wound
healing and other healthy diet choices to
reduce hypertension, taking medications as
directed

Discharge
planning

Discuss family involvement with care,

promote for safe home environment for
patient, wound care, medication
education

Home care: taking prescribed antibiotics

and other medications as directed, keeping
wounds clean, keeping affected area
elevated. Safe PT/OT techniques to
perform ADLs. Appoint with social worker
to discuss any concerns patient may have.

Nursing
Diagnoses
(NANDA)

Expected
(complete before assessment)

Found
(complete after assessment)

1.

1. Altered oxygenation related to acute

hypoxic respiratory failure and bilateral
pneumonia as evidenced by lung sounds
clear with decreased fine crackles to
bases, 5L O2 nasal cannula with weaning
order to maintain O2 sat > 92%,
documentation of desaturation levels upon
ambulating as tolerated, need for home
oxygen.
2. Fatigue related to activity orders to
ambulate 3-4 times a day, documentation
of desaturation levels upon ambulating
around unit with recovered O2 sat levels >
92%, patient reports needing more time to

Altered oxygenation related to acute

hypoxic respiratory failure and
bilateral pneumonia as evidenced by
chest x-ray reveals small bilateral
pleural effusions, oxygen given via
nasal cannula, documentation of
inconsistencies and instability of O2
saturation levels upon ambulating.
2. Fatigue related to up to ambulate as
tolerated as evidenced by
documentation of patient reporting
feeling tired after walking around unit,
desaturation levels upon and after
ambulation.

recover with lower O2 levels, labored

breathing after ambulating, need for home
oxygen.

Focus of
physical
assessment

V/S, Respiratory assessment (O2 sat,

respiration rate and rhythm, lung sound
characteristics, note cyanosis or skin
temp, use of accessory muscles), LOC,
mental status, activity tolerance, bowel
and bladder elimination patterns, address
any concerns patient may have,
cardiovascular assessment, skin integrity

V/S, check oxygen level, respiratory

assessment (O2 sats, respiration rate and
rhythm, lung sounds, skin color and temp, use
of accessory muscles), use of incentive
spirometer, baseline and change in LOC,
cardiovascular assessment, any pain, I/O,
bowel and bladder elimination, skin integrity,
concerns patient has

Need more
information
from
patient/family/
doctor about:

Family support, plan to go home to Maui,

why PT/OT discontinued?, assess
patients knowledge on condition,

Arrangements for patient pick-up in Maui by

patients wife after discharge, arrangements
for home oxygen delivery, consults and followup with infectious disease physician regarding
pneumonia and general surgery regarding
ulcerative colitis

Top three
priorities
(goals) for
patient care

1. Oxygenation status
2. Activity tolerance
3. Bowel and bladder elimination pattern

1.
2.
3.
4.

Nursing
Interventions

1. Assess respiratory rate, depth, and

effort, including use of accessory
muscles, nasal flaring, and abnormal
breathing patterns. Assess lungs for
areas of decreased ventilation and
auscultate presence of adventitious
sounds. Monitor s/s of atelectasis
such as crackles. Observe for
cyanosis. Assess for headache,
dizziness, lethargy. Monitor O2 sat
closely. Assess patients ability to
cough out secretions. Evaluate
hydration status.
2. Monitor patients behavior and mental
status for onset of restlessness,
agitation, confusion, extreme lethargy.
3. Position with HOB elevated.
Encourage and assist with ambulation
per MD order. Instruct and encourage
use of incentive spirometer to
promote optimal lung expansion.
4. Assist with ambulation. Provide
portable oxygen. Allow for rest
periods as needed.
5. Administer medications as ordered.
6. Monitor I/O.

1. Assess respiratory rate, depth, and effort,

including use of accessory muscles, nasal
flaring, and abnormal breathing patterns.
Assess lungs for areas of decreased
ventilation and auscultate presence of
adventitious sounds. Monitor s/s of
atelectasis such as crackles. Observe for
cyanosis. Assess for headache, dizziness,
lethargy. Monitor behavior and mental
status.
2. Maintain oxygen administration device and
wean as ordered to maintain O2 sat >
92%. Monitor O2 sat closely. Assess
patients ability to cough out secretions.
Evaluate hydration status.
3. Position with HOB elevated. Encourage up
to chair for meals. Encourage and assist
with ambulation per MD order and provide
portable oxygen. Instruct and encourage
use of incentive spirometer to promote
optimal lung expansion. Help with cough
and deep breathing.
4. Provide reassurance and reduce anxiety.
Pace activities and encourage rest periods
to prevent fatigue.
5. Administer medications as ordered.

Oxygenation status
Activity tolerance
Bowel and bladder elimination pattern
Discharge planning

6. Monitor I/O.

Teaching
needed/provid
ed

Use of incentive spirometer, cough and

deep breathing, home oxygen use, safe
ambulation techniques with rest periods
to prevent fatigue, medication education

Use of incentive spirometer, cough and deep

breathing, home oxygen use, safe ambulation
techniques with rest periods to prevent
fatigue, medication education.

Discharge
planning

Patient needs to be able to maintain

adequate O2 sat at 3L O2 in order to fly
home to Maui

Case management to arrange discharge,

home oxygen delivery,