Ineffective airway clearance related to dry
mucous membranes as evidenced by inability
to cough up secretions, thick mucous
secretions, difficulty swallowing
**Monitor Sp02, suction oral cavity secretions
every hour, HOB elevated 45 degrees, assess lung
sounds and RR (maintained at 12 – 20 br/min),
assess oral cavity and airway for patency
**The patient will demonstrate effective cough,
breath sounds will be clear, no cyanosis and
dyspnea (capable of removing the sputum,
breathes easily, no pursed lips), has a patent
airway (does not feel suffocated, breath rhythm
and respiratory frequency in the normal range, no
abnormal breath sounds)
Risk for aspiration related to dysphagia, thick
mucous secretions, decreased level of
consciousness, depressed cough
**Provide oral hygiene to decrease risk for
infection should aspiration occur, elevate HOB at
45 degrees, suction PRN, assess LOC, assess
ability to swallow, assess nutrition status, insert
NG tube if patient cannot tolerate intake), provide
adequate IV fluids, monitor for s/s of infection,
assess lung fields for crackles
**The patient will be free of aspiration, maintain
a patent airway, and be free of pneumonia or
other lung infection
Decreased tissue perfusion related to as evidenced by
decreased BP, decreased fluid intake, infection as
evidenced by capillary refill > 4 seconds, cold
extremities, non-palpable pedal pulses
**Assess extremities for diminished tissue perfusion,
document baseline mental status and monitor for
improvement (if diminishing, assess for decreased
perfusion to brain), place SCD on patient’s legs, keep
patient warm, provide IV fluids
**The patient will demonstrate BP within normal range
for client, baseline mental status, extremities warm with
absence of pallor and cyanosis, palpable peripheral
pulses, capillary refill<3 seconds, absence of edema,
urine output at least 30 ml/hour
Infection related to the state of the nutrition as
evidenced by elevated WBC count, positive bacteria
culture, fever,
**Administer IV antibiotics (Cefazolin), improve fluid
status, provide wound care, monitor temperature,
**Upon adherence to IV antibiotics, patient will be free
of infection as evidenced by normal vital signs, and
absence of purulent drainage from wounds
Reason for Seeking Health Care
-E.J. is an 88 YO AA Male who presented to the ED on
12/01 with lethargy and acute confusion as a result of severe
dehydration. His daughter states that his live-in girlfriend
has neglected to care for him in the recent months and states
that his girlfriend let him lie on the couch for 7 plus days
without care. E.J. was unable to eat or drink for this period of
time and also was forced to void on himself because his
girlfriend would not assist him to the bathroom.
Present illness:
-E.J. has dry skin, ulcerative lesions, dry mucous
membranes, severe agitation coupled with delirium,
increased temperature of 99.6F, increased heart rate
(120 – 144), decreased blood pressure (90/44), positive
for gram+ staphylococcus infection
Pertinent laboratory results:
Na+ 155 (high), K+ 3.8, Cl- 119 (high), BUN 13.1
(high), Creatinine 3.4 (high), WBC 26,000 (high),
Platelet ct 649mm3 (high)
Past medical/surgical history
Hypertension, confirmed delirium, constipation,
penile cancer,
Medical diagnosis
Dehydration: lack of fluids and electrolytes required
to meet the body's needs
Impaired skin integrity related to physical immobilization, dry skin as evidenced by
early-stage pressure ulcer in the left heel
(redness, inflammation, pressure, and
tenderness and warmth in the left heel), dry,
cracked non-elastic skin turgor, stage-2 ulcer
on left coccyx region.
**Monitor for s/s of infection (redness, swelling,
increased pain, purulent drainage from ulcers,
temperature of 99.8 or greater), WBC (should not
rise above 10,000mm3), assess current open ulcer
wounds, and assess nutritional status, enhance
mobility (to help reduce chances of stasis ulcers,
improve current ulcers, and to enhance blood
perfusion), provide adequate skin care, encourage
fluid intake/start IV fluids
**The patient will demonstrate no new abrasions,
will have elastic skin turgor upon rehydration,
will have marked improvement of current ulcers
on skin, will have clean/dry skin
Fluid volume deficit related to inadequate
fluid intake, electrolyte imbalances, increased
metabolic rate, and fluid shifts as evidenced by
dry mucous membranes, inelastic skin turgor,
edema of lower extremities, fever, decreased
urine output, capillary refill > 4 seconds,
decreased mental status, elevated platelet
count, elevated Na+, elevated BUN, elevated
creatinine.
** Monitor urinary output (notify physician if
UOP<30ml/hr), administer IV NS, administer IV
heparin (monitor PT/INR), assess urine color,
assess skin turgor and mucous membranes),
document baseline mental status and monitor for
improvement, monitor blood pressure (giving
fluids increases risk for fluid overload and cardiac
problems)
**The patient will regain adequate fluid volume
and electrolyte balance as evidenced by urine
output>30 ml per hr, normotensive blood
pressure, heart rate between 80 – 100 beats per
min, consistency of weight, and normal skin
turgor