Diagnosis
Desired Outcomes
Interventions
Acute Pain
Client pain will be managed.
Client will be able to express/verbalize decreased pain.
Impaired Physical
Mobility
Client will be able to safely ambulate and perform ADLs with minimal
or no assist using assistive devices.
Assess pain characteristics (guarding of site,
grimacing, and restlessness)
Respond immediately to complaint of pain.
Assess the patient's expectations for pain relief.
Determine the appropriate pain relief method:
Pharmacological or Non-pharmacological: deep
breath, distraction, re-positioning
Perform ROM to all extremities and bear weight
as tolerated daily.
Assess all body systems for complications related
to impaired physical mobility, especially post op.
Assist client in creating a PT/OT plan for home
with family support.
Physical therapy consults regarding ambulation
and transferring pre and post op.
Occupational therapy consult regarding ADLs pre
and post op.
Ineffective
Breathing Pattern
Client will maintain an effective breathing pattern, AEB relaxed
breathing at normal rate and depth with absence of dyspnea.
Client will be able to adequate oxygenate self and not rely on nasal
cannula.
Assess respiratory rate, rhythm, and depth.
Monitor breathing patterns.
Sit client in upright position to promote aeration.
Assess skin color and temperature
Monitor for levels of consciousness.
Assess for thoracic or upper abd pain
Assess nutritional status. Promote healthy dietary
choices.
Ineffective Tissue
Perfusion
Client maintains optimal cardiopulmonary perfusion AEB eupnea,
blood pressure within normal range for patient, absence of chest pain,
warm and dry skin, palpable peripheral pulses, normal ABGs, absence
of adventitious breath sounds, and urinary output greater than or
equal to 30mL/hr.
Assist with position changes
Promote active/passive ROM.
Maintain adequate ventilation and perfusion as in
the following: place client in semi- to high
Fowler’s position as tolerated // Administer
oxygen therapy as prescribed
Administer medications as prescribed to treat
underlying problem. Note response.
Decreased Cardiac
Output
Patient has adequate cardiac output as evidenced by systolic BP
within 20 mm Hg of baseline; urine output greater than or equal to 30
mL/hr; strong peripheral pulses; warm, dry skin; eupnea with absence
of pulmonary crackles; and orientation to person, time, and place.
Assess for changes in LOC
Assess heart rate and blood pressure
Assess skin color, temperature, and moisture
Assess fluid balance and weight gain
Assess heart sounds for S1,S2, gallops
Assess for complaints of fatigue and reduced
activity tolerance
Assess for chest pain
Administer medication as prescribed, noting
response and watching for side effects and
toxicity. Clarify with physician parameters for
withholding medications.
Administer stool softeners as needed.
Risk for Infection
Client is free of infection, as evidenced by normal vital signs, labs and
absence of local signs of infection like purulent drainage, redness,
warmth and pain from wound and surrounding areas.
Monitor for the following signs of infection:
Redness, swelling; increased pain; purulent
drainage from incisions, injury, and exit sites of
tubes, drains, or catheters.
Monitor white blood cell (WBC) count.
Wash hands and teach other caregivers to wash
hands before contact with patients and between
procedures with the patient
Maintain or teach asepsis for dressing changes
and wound care, catheter care and handling, and
peripheral IV and central venous access
management.
Administer and teach use of antimicrobial
(antibiotic) drugs as ordered.
Incomplete
Emptying of
Bladder
Client empties bladder completely AEB urine volume greater than or
equal to 300mL with each voiding and residual volume less than
100mL.
Evaluate previous patterns of voiding.
Visually inspect and palpate lower abd for
distention.
Evaluate time intervals between voiding, and
record amount voided each time.
Catheterize client or use bladder scan to measure
residual urine if complete emptying is susptected.
Determine balance between intact and output.
Impaired Tissue
Integrity
Client’s tissues return to an as optimal as possible state in structure
and function, while preventing further damage and infection.
Assess for elevated body temperature and
patient's level of discomfort.
Assess condition of tissue, characteristics of the
wound, including color, size, drainage, and odor.
Provide skin care as ordered/needed:
premedicate & maintain sterile technique.
Administer antibiotics and other medications as
ordered.
Encourage nutritional intake to promote wound
healing.
EVALUATION:
Acute Pain/Anxiety – Client given pain medications upon request. Client no longer grimacing, guarding affected limb or saying “owie”. Client is
helpful when being repositioned in bed. (goal met during shift)
Impaired Tissue Integrity/ Infection – Client wound is clean, dry and intact. No visual signs of redness, swelling or warmth at site. (goal met
during shift)
Decresed Cardiac Output – Client blood pressure not controlled at this moment. BP- 176/67. Client currently on blood pressure meds
(Lisinopril), and receiving oxygen via nasal cannula (1LPM). Monitored labs showed a decrease in Hgb & Hct. Client is stable. (goal partially met
during shift)
Impaired Tissue Perfusion / Ineffective Breathing Pattern – Client is currently receiving 1LPM oxygen therapy via nasal cannula. Client O2 sats
>95%, and temperature was 97.7F. Client did not express any difficulty breathing or expresses any signs of restlessness or fatigue. (goal met
during shift).
Discharge Planning –
Client’s son serves as the designated decision maker. After collaboration with client’s primary physician, physical therapist, and occupational
therapist, has decided that client will be discharged to a Hale Nani - SNF for short term rehab. Once client has successfully completed her
treatment plans, she will then return to her residence where she will receive care from her caregiver.
Client Education/Caregiver EducationDemonstration and repeat performance will be the main method of teaching with an emphasis on infection prevention, safety precautions, and
noticing any deviations from normal daily functions pertaining to this client. Maintaining proper nutrition, proper use of assistive devices,
monitoring elimination patterns, and medication administration will also be provided during and after admissions.
References:
Gulanick, M., & Myers, J. (2011). Nursing care plans: diagnoses interventions, and outcomes. (7th ed ed.). PA: Mosby.
Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., et al, L., & Camera, I. M. C. (2011). Medical-surgical nursing, assessment and
management of clinical problems. (8th ed. ed.). St. Louis, Missouri: Mosby