C/V: Inadequate tissue perfusion
related to decreased blood volume
as evidence by low HGB/HCT
Continuous EKG telemetry: Sinus Rhythm
and Regular
12 lead EKG Q8H X4 SR with non specific ST
T-wave changes
Interventions:
1. Assess heart sounds, edema, JVD,
peripheral pulses, capillary refill Q2 hours
and PRN. S1, S2. No S3, peripheral pulses
(radial left & right 2+) (dorsalis pedis left &
right 1+ thready), capillary refill (<3
seconds)
2. Check Blood count QD. WBC (11.6) RBC
(3.95) HGB (8.2) and HCT (28%)
Administer blood as ordered.
3. Assess HR and BP q hour and PRN with
any changes in assessment/pain.
4. Daily weight admitted (58.3 kg) and now
(55.6 kg) so lost 2.7 kg
Goals:
1. No changes in EKG. (Goal Met)
2. Weight above or = 58.3. (Goal
Met)
3. No decrease in RBC, HGB and HCT
count and no increase in WBC
count. (Goal Met)
Resp: Impaired respiratory function
related to coarse lung sounds and
increased sputum as evidence by
low pH (metabolic acidosis)
Interventions:
1. Assess RR, WOB, use of accessory muscles, dyspnea
at least Q 2H and with each interaction. RR 19/min, No
increased WOB noted, no use of accessory muscles
noted. Dyspnea when moving and when suctioning.
2. Monitor SaO2 continuously. SaO2 96-100%
currently on 6L Nasal Canula (she was intubated with
ET and on assist-control; T piece O2 % = 35)
3. Monitor CXR Qday and PRN- Diffuse pulmonary
airspace opacities have worsened. Layering pleural
effusions. Line on left side indicating pneumothorax.
4. Assess lung sounds Q2H and prn with changes.
Coarse lung sounds. Left and right lower lobes are
diminished.
5. Assess sputum when suctioning for signs of
infection. Scant, cream, thick
6. ABGs every shift; at 12:00 pm. pH (7.29) PCO2
(33.7) PO2 (96.5) & HCO3 (16.5): Metabolic Acidosis
Lactic Acid (0.7)
Goals
1. RR 16-20 (Goal Met)
2. No use of accessory muscles, increased WOB, SOB,
dyspnea, &/or adventitious breath sounds. CXR clear
SaO2 >95% on supplemental O2 (Goal Partially Met)
3. ABGs within normal range (Goal not met)
Present Illness: 84 yo female came to ED
11/01/14 with c/o nausea, vomiting, fever and
chills. Ex lap found peptic ulcer perforation and
cecal mass. On 11/03/14 patient had
ileocolostomy and was intubated with fentanyl
continuously to help with pain and sedation. On
11/06/14 patient was extubated and is now on 6L
nasal canula until further orders are initiated.
Patient is also on standard contract precautions
because of her recent diagnosis of shingles.
Past Medical History:
CHF,
cataracts, & cholecysectomy .
Medical Diagnosis:
Neuro: Potential decrease in LOC
related to acid base imbalances.
Interventions:
1. Neuro checks Q 2 hours and PRN WNL
Glasgow coma scale 11, weakness, alert LOC,
can’t assess speech due to E-T tube
2. Provide patient with date, and staff names on
dry erase board in room. done
3. Clock with the correct time in patient’s line of
sight done
4. Assess sensory Q 2 h. Sensory slightly limited
5. Reorient patient PRN
Fever
Nursing Diagnosis:
Risk for Acid and
base imbalance related to low pH, pCO2 and HCO3
levels
Skin: Risk for impaired skin integrity
related to decreased oxygenation to the
tissues as evidence by low HCT/HGB &
decreased mobility due to post op
ileocolostomy.
Interventions:
1. Assess skin for color, turgor, temperature, &
sensation Q 2h. Pink, warm, dry, non-elastic, not
intact
2. Assess cap refill Q 2 hours (see CV)
3. Monitor bony prominences for redness or
breakdown with interactions Q 4 hours No
redness or breakdown noted
4. Assist with turning Q 2H and PRN. Turned self
Q2H
5. Ensure bedding is dry and free of wrinkles Q 4
hours. & PRN.
6. Assess mucous membranes Q 2h. Pink and
moist
Goals
No breakdown. Skin remain intact, warm, pink,
normal turgor, and sensation. Goals partially
met
GI: Potential for imbalanced nutrition: less
than body requirements related to NPO status
due to abdominal surgery.
1. Monitor bowel sounds Q2h. Hypoactive; no
passing flatus
2. Inspect abdomen for any distension Q 2h:
Rounded/ Soft/ Tender/ Distended
3. Monitor for signs of infection by inspecting the
abdomen Q 2 h. Soft and Tender
4. Keep patient NPO until further instructed due
to abdominal surgery.
Goals: Normal Bowel sounds, BM at least Q
2days, no straining. NPO until further instructed.
Goal partially met
Goals:
1. GCS remain at or above 11. Goal Met
2. Remain A & O with neuro checks WNL.
Goal Met
Muscular: Activity intolerance R/T
post op ileocolostomy.
Fall precautions and Bed rest. Very limited mobility.
Interventions:
1. Assess ADLs QD. ADLs with moderate assistance.
2. Make sure SCD are on to prevent blood from clotting from
being bed-ridden. Done.
3. Active assist ROM Q 2 H done (with physical therapist:
sitting up and dangling on side of bed for 5 minutes)
4. Assess and compare Rt and Lt side for strength, mobility
&/or limitations. RT and Lt side equal
Goals: ADLs performed without any discomfort and our
pain. Goal Met
Pain:
Acute pain
R/T post op
ileocolostomy
Interventions:
1. Increase O2, give
Morphine PRN (done)
2. Reassess
interventions within
10 minutes. (done)
3. Monitor for verbal/
nonverbal S/S of pain.
Pain with activity such
as getting up in bed.
Goals:
Pain level reduced
Goal met
Endocrine:
decreased BS related
to NPO status.
Interventions:
1. Monitor BS 7, 11, 4, 9 1200 BS
59 mg/dL
2. Monitor for S/S hyper or
hypoglycemia. No increased
thirst, shaking, tachycardia,
urination, change in LOC, or
diaphoresis noted.
3. Ensure patient is eating
adequately: NPO status
4. Administer glucose PRN: Done
Monitor HgbA1C. Ordered-no
results.
Goals:
1. BS 100-170 and no S/S of
hyper or hypoglycemia. HgbA1C
<7.5. Goal Met
GU: Potential decrease in kidney tissue
perfusion related to decreased blood
volume as evidence by low H&H
Interventions:
1. Intake and output @ least every 2 hours. 100 at 12:00
pm
2. Notify MD for UOP <30 cc/hr.
3. IV- NS at 50 cc/hr Done
4. Assess urine. Yellow & concentrated
5. Assess for bladder distention Done
6. Assess foley catheter for signs of infection Q 2h Done
7. Monitor BUN & Creat daily or as ordered by MD Done
Goals:
UOP >30 cc/hr, BUN <25 and creat < 1.2 Goal Met