4. Impaired Oxygenation
o Ineffective airway clearance
related to increased
production of thick mucus
o AEB O2 medications
5.
o
o
o
o
Pain Management
Related to Incision Site
Related to ostomy site
Allergies: Latex, ibuprofen
Nursing Progress notes said
patient was intermittently
irritable
3. Risk for Impaired Skin
Integrity
o Related to ostomy site,
difficulty obtaining tight seal
of appliance
A.H.
17 months
CF,
Ileostomy
Sept 25/06
1. Sleep Pattern Disturbance
o Related to internal factors
of illness effects (CF)
o New ostomy appliance
o Charts mentioning “did not
sleep well”
o Pain
2. Risk for Infection
o Related to chronic pulmonary
disease
o Related to Ileostomy
o Related to IV site
o Related to PICC site
o Related to chronic illness
and decreased immune
system
Parking Lot
Pain
CSM
Temperature
Skin
6. Fever
o Hyperthermia related to
cystic fibrosis
o Chest X-ray needed if
temperature is 38C or higher
Problem
Intervention
Obtain a sleep history including bedtime routines, history of
sleep problems, changes in sleep with present illness and use of
medications and stimulants
Sleep Pattern
Disturbance
Assess level of pain and use of available pharmacological and non
pharmacological approaches to pain management
Provide pain relief shortly before bedtime and position the client
comfortably for sleep
Keep environment as quiet as possible for sleeping; anticipate IV
monitors and other hospital machines
Observe and report signs of infection such as redness, warmth,
discharge and increased body temperature
Risk for Infection
Note and report laboratory values (eg. White blood cell count
and differential, serum protein, serum albumin, and cultures)
Assess skin for colour, moisture, texture and turgor. Keep
Evaluation
accurate ongoing documentation of changes. Preventative skin
assessment protocol, including documentation, assists in the
prevention of skin breakdown
Carefully wash and pat dry skin, including skin fold areas. Use
hydration and moisturization on all at-risk surfaces.
Encourage Fluid Intake
Measure and record a febrile client’s temperature at least every
4 to 6 hours or whenever a change in condition occurs.
Use the same site for temperature measurement for a given
client so that temperature trends are assessed accurately
Fever
Administer anti-pyretic medication per physicians orders, when
infection-induced fever is above 40C and when the client cannot
tolerate the increase in metabolic demand
Assess fluid loss and facilitate oral intake or administer
intravenous fluids to accomplish fluid replacement
Monitor respiratory rate, depth and ease of respiration.
Note abdominal breathing, use of accessory muscles, nasal
flaring, retractions, irritability, confusion, or lethargy
Impaired
Oxygenation
Auscultate breath sounds, noting decreased or absent sounds,
crackles, or wheezes
Monitor client’s oxygen saturation and blood gases
Monitor for presence of pain and provide pain medication for
comfort as needed
If the client is cognitively impaired and unable to report pain and
use a pain rating scale, assess and document behaviors that might
be indicative of pain
Pain Management
Assume pain is present and treat accordingly in a client who has a
pathological condition or who is undergoing a procedure thought
to be painful
For a young child use a Faces Pain Scale to determine the level of
pain present
Plan care activities around periods of greatest comfort whenever
possible
Monitor skin at least once a day for colour or texture changes,
dermatological conditions, or lesions. Determine whether the
client is experiencing loss of sensation
Risk for Impaired
Skin Integrity
Monitor the client’s skin practices, noting type of soap or other
cleansing agents used, temperature, frequency of skin cleansing
Use a risk assessment tool to systematically assess immobilityrelated risk factors
If consistent with overall client management goals, teach how to
turn and reposition the client at least every 2 hours