Assessment

1.75

Nursing DX/Clinical Problem

1.49

Client Goals/Desired Outcomes/Objectives

2

Nursing Interventions/Actions/Orders and Rationale

1.75

*I

Evaluation

2

Goals

Interventions

Subjective

Patients statements of:

“I can only walk about 50 steps before I become short of breath”

“I use 2 pillows at night to help me breathe.”

Absent cough

Objective

BUN- 35

Cr- 1.90

Hgb- 10.4

Hct- 31.0

Diminished breath sounds in bilateral lower lobes.

Problem

Excess fluid volume

Ineffective airway clearance

Long Term:

Patient will meet and maintain a fluid intake appropriate for him by discharge.

Patient will remain free of hypoxemia until discharge. 

Calculate an appropriate daily fluid in take amount and work with patient to establish an intake goal.

EBP: Effectively helps hemodialysis patients adhere to fluid restrictions (Ackley and Ladwig, pg. 377).

Administer oxygen as needed.

EBP: Corrects hypoxemia (Ackley and Ladwig, pg. 126).

*

Goal met. Client reports that it isn’t as hard as he thought it would be to restrict his fluid intake.

Goal met. Client free of hypoxemia throughout length of stay and kept oxygen on at all times.

Continue to monitor and document fluid intake.

Oxygen: 1L NC administered and maintained. Patient currently free of hypoxemia.

R/T

Congestive heart failure

COPD secondary to long history of smoking

Short Term:

Patient will verbalize understanding of how to monitor weight changes by end of assessment.

Patient will cough and deep breathe 10 times every hour.

Monitor daily weight for sudden increases.

EBP: Safe way to monitor for fluid volume overload (Ackley and Ladwig, pg. 376).

Help patient to cough and deep breathe and perform controlled coughing.

EBP: uses diaphragmatic muscles. Cough is more forceful and effective (Ackley and Ladwig, pg. 125 and 126).

*

Goal met. Patient correctly identifies that monitoring his weight every morning is the most effective way to indicate fluid volume overload.

Goal met: Patient coughs and deep breathes 10 times every hour.

Patient now able to weigh himself every morning.

Teaching has been implemented. Assess lung sounds every shift and document any changes.