Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective:

Client verbalized statements indicative of confusion.

Objective: 

Client has a chest tube to treat a pneumothorax.  Client has an increased AP diameter.  Client was breathing through his mouth and not his nose (which had a nasal cannula).  O2 saturation was in the 80’s while patient was mouth-breathing and in the 90’s while nasal breathing.    Client had an abnormal breathing pattern, restlessness, and visual disturbances.

Problem:  Impaired gas exchange

Long Term:

Client will demonstrate improved ventilation and adequate oxygenation as evidenced by blood gas levels within normal parameters for this client by 09:00, 2/23/09.

-Assess nutritional status including serum albumin level and body mass index. Weight loss in a client with COPD ha a negative effect on the course of the disease; resulting in a loss of muscle mass and in the respiratory muscles which can lead to respiratory failure  (Celli & MacNee, 2004).

-Help the client eat small frequent meals and use dietary supplements as necessary.  Having a BMI less than 21 has been associated with earlier mortality in patients with COPD  (Schols et. al, 1995)
-monitor patient’s blood gas levels

*

Evaluation of this goal is set for 22:00, [Month] 23, [Year].  Reminders to breathe through his nose improved pulse oximetry measurements of saturation.  Some progress made towards goal.  

Client’s serum albumin is low and the BMI is 16.2. Assessment complete, continued monitoring required.  Help client eat sorbet, administered nutritional supplements.  Intervention achieved today, continuation required.

Blood gas levels not drawn, this intervention not achieved, re-evaluation set for 22:00, [Month] 23, [Year].

R/T:

Alveolar-capillary membrane changes and ventilation-perfusion imbalance

Short Term:

Client will maintain clear lung fields and remain free of signs of respiratory distress by 12:30,  2/17/09.

-Monitor respiratory rate, depth and effort.

-Monitor client’s behavior and mental status for the onset of restlessness.  Changes in a client’s mental status can be an early sign of impaired gas exchange  (Simmons & Simmons, 2004).

-Monitor client’s oxygen saturation continuously by pulse oximetry.  The goal of inpatient therapy for the client with COPD is to maintain the oxygen saturation greater than 90% and PaO2 at or above 80 mm Hg to maintain cellular oxygen  (Celli & MacNee, 2004)

-Position client in the semi-Fowler’s position.  Research indicates that the 45 degree position facilitates breathing and reduces the risk of pneumonia (Speelberg & Van Beers, 2003).

-Remind the client to breathe through his nose and not his mouth

*

Client’s lung fields were clear to auscultation and client was calm and free of signs of respiratory distress by 12:30, [Month] 17, [Year].

Monitored client’s respiratory rate, depth, effort, behavioral and mental status.  Monitored client’s pulse oximetry and cued client to breathe through nose when SaO2 dropped below 90%. 

Positioned client in the semi-Fowler’s position to facilitate breathing.  Client’s SaO2 and calm demeanor indicative of no respiratory distress, interventions successful.

AEB:

Pulse oximetry below 90%, barrel chest, restlessness, confusion, visual disturbances (hallucinations), abnormal breathing pattern.

Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective:

Client not hungry, turns away from food, spits it out, expressed confusion regarding where he was

.

Objective: 

Client has developed urinary incontinence, hyperactive bowel sounds upon auscultation, change in bowel pattern, unable to pass stool, and   no BM within the past 7 days, and has a serum K+ and Ca+  level that are low.

Problem:  Constipation

Long Term:

Client will maintain passage of soft, formed stool every 1-3 days without straining by 12:00, [Month] 19, [Year].

-Promote regular consistent toileting each day based on the client's triggering meal. Safeguard the client's visual and auditory privacy when toileting  (AHRQ, 2005)

*

Evaluation of this goal is set for 17:00, [Month] 23, [Year].  No progress made. 

Evaluation of this intervention is set for 17:00, [Month] 23, [Year]. Intervention unsuccessful to date.  Further evaluation required.

R/T:

Inadequate toileting, insufficient physical activity, mental confusion, calcium carbonate supplements, and electrolyte imbalance.

Short Term:

Client will have a bowel movement within 6 hour shift on [Month] 17, [Year].

-Assess client’s bowel hx, determine date of last bowel movement

-Palpate for abdominal distention, auscultated for bowel sounds.  In clients with constipation, the abdomen is often distended and tender, bowel sounds are present (Hinrichs, et al, 2001)

-Provide laxatives, stool softeners and enema as ordered

-When giving soap suds enema, measure the amount of fluid given and the amount expelled.  Enema fluid can be retained and damage epithelium  (Hinrichs, Huseboe, & Tang, 2001)

*

Client did not have a bowel movement.  Goal not achieved.  Further assessment required to facilitate achievement of the goal.

Assessed client’s bowel movement history, palpated for abdominal distention (none present), and auscultated bowel sounds (hyperactive).  No tenderness noted.  Provided laxative, stool softener and enema as ordered.   Measured amount instilled, estimated amount expelled.  Interventions achieved but were unsuccessful.  Further assessment required to reevaluate interventions utilized and whether they meet the underlying issue.

AEB:

Patient self-assessment of pain rated an 8 on a scale 0f 0-8, generalized pallor, self-report of nausea r/t pain quality, restlessness, and distractibility.