Nursing Care Plan: Pulmonary Ebolism
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- Words: 459
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Assessment (Supporting data)
Subjective: “I can’t breathe”
Objective: Restless, ↓ O2 sats
Nursing Diagnosis (NANDA diagnostic statement)
Goals & Expected Outcomes (Realistic, timed, measurable)
Impaired Gas Exchange R/T inability to transport oxygen AEB hypoxemia and cyanosis
Pt will not develop pulmonary complications during hospital stay Pt’s O2 sat will remain >95% during hospital stay Respirations will remain 12-20 BPM ABGs will be NML at least 24 hours before D/C (PaO2 80-100; PaCO2 35-45; pH 7.357.45)
Nursing Interventions (Strategies or actions for care) Rationale for interventions
•
• •
•
•
•
Continuous pulse ox Assessment of pt’s baseline O2 sats is necessary to titrate O2 Baseline ABGs Titrate O2 to keep sats > 95% Ensures adequate perfusion to tissues Teach pt IS use every 2 hours while awake Helps prevent atelectasis Encourage cough, repositioning, and deep breathing Q 2 hours Helps prevent atelectasis Instruct pt not to cross legs or wear tight stockings Impairs venous return; increases risk of PE
Evaluation (Client’s response to nursing actions & progress toward achieving goals & outcomes)
Pt did not develop pulmonary complications during hospital stay Respirations will remain 12-20 BPM Respirations remained 12-20 BPM
Subjective: “My pain is 9/10”
Objective: moaning, guarding
Acute Pain R/T tissue ischemia AEB guarding, moaning, verbal rating of pain 9/10
Within 1 hour of intervention, pt’s subjective pain level will decrease. Objective indicators of pain (grimacing, moaning) will diminish.
•
•
Pt will maintain adequate pain control during hospital stay •
•
Pre medicate before activities Provides comfort during activity Encourage pt to request pain meds before pain becomes severe or administer at scheduled intervals Prolonged stimulation of pain receptors results in increased sensitivity to pain, increasing the amt of drug needed to relieve pain Help pt with nonpharm pain management (relaxation, distraction, positioning, etc.) Teach pt to splint chest when coughing, moving Reduces discomfort and increases compliance with TCDB
Pt reported pain relief of 2/10 after administration of morphine
Assessment (Supporting data)
Nursing Diagnosis (NANDA diagnostic statement)
Goals & Expected Outcomes (Realistic, timed, measurable)
Nursing Interventions (Strategies or actions for care)
Evaluation (Client’s response to nursing actions & progress toward achieving goals & outcomes)
Subjective:
Risk of Fluid Volume Deficit R/T acute blood loss Objective:
Pt remains normovolemic throughout hospital stay Pt shows no signs of external or internal hemorrhage Pts VS remain stable (BP WNL, RR 12-20, HR 6080)
• • •
• •
•
Monitor I&O Pt did not hemorrhage Weigh patient during hospital stage daily Monitor lab values to eval lytes, h&h and fluid balance These assessments all eval fluid , lyte and hemo status Monitor stool for occult blood Monitor for sudden thirst Indicative of hemorrhage Inform pt to use
•
electric razors, soft toothbrushes, etc. to avoid bleeding Institute fall precautions
Subjective: “I can’t breathe”
Objective: Restless, ↓ O2 sats
Nursing Diagnosis (NANDA diagnostic statement)
Goals & Expected Outcomes (Realistic, timed, measurable)
Impaired Gas Exchange R/T inability to transport oxygen AEB hypoxemia and cyanosis
Pt will not develop pulmonary complications during hospital stay Pt’s O2 sat will remain >95% during hospital stay Respirations will remain 12-20 BPM ABGs will be NML at least 24 hours before D/C (PaO2 80-100; PaCO2 35-45; pH 7.357.45)
Nursing Interventions (Strategies or actions for care) Rationale for interventions
•
• •
•
•
•
Continuous pulse ox Assessment of pt’s baseline O2 sats is necessary to titrate O2 Baseline ABGs Titrate O2 to keep sats > 95% Ensures adequate perfusion to tissues Teach pt IS use every 2 hours while awake Helps prevent atelectasis Encourage cough, repositioning, and deep breathing Q 2 hours Helps prevent atelectasis Instruct pt not to cross legs or wear tight stockings Impairs venous return; increases risk of PE
Evaluation (Client’s response to nursing actions & progress toward achieving goals & outcomes)
Pt did not develop pulmonary complications during hospital stay Respirations will remain 12-20 BPM Respirations remained 12-20 BPM
Subjective: “My pain is 9/10”
Objective: moaning, guarding
Acute Pain R/T tissue ischemia AEB guarding, moaning, verbal rating of pain 9/10
Within 1 hour of intervention, pt’s subjective pain level will decrease. Objective indicators of pain (grimacing, moaning) will diminish.
•
•
Pt will maintain adequate pain control during hospital stay •
•
Pre medicate before activities Provides comfort during activity Encourage pt to request pain meds before pain becomes severe or administer at scheduled intervals Prolonged stimulation of pain receptors results in increased sensitivity to pain, increasing the amt of drug needed to relieve pain Help pt with nonpharm pain management (relaxation, distraction, positioning, etc.) Teach pt to splint chest when coughing, moving Reduces discomfort and increases compliance with TCDB
Pt reported pain relief of 2/10 after administration of morphine
Assessment (Supporting data)
Nursing Diagnosis (NANDA diagnostic statement)
Goals & Expected Outcomes (Realistic, timed, measurable)
Nursing Interventions (Strategies or actions for care)
Evaluation (Client’s response to nursing actions & progress toward achieving goals & outcomes)
Subjective:
Risk of Fluid Volume Deficit R/T acute blood loss Objective:
Pt remains normovolemic throughout hospital stay Pt shows no signs of external or internal hemorrhage Pts VS remain stable (BP WNL, RR 12-20, HR 6080)
• • •
• •
•
Monitor I&O Pt did not hemorrhage Weigh patient during hospital stage daily Monitor lab values to eval lytes, h&h and fluid balance These assessments all eval fluid , lyte and hemo status Monitor stool for occult blood Monitor for sudden thirst Indicative of hemorrhage Inform pt to use
•
electric razors, soft toothbrushes, etc. to avoid bleeding Institute fall precautions
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