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Assessment
Subjective:
Patient states: I
feel pain in my
left hip and leg,
and is getting
worst when I
move
Cultural:
Patient married
for 40 years, 3
children and one
5-yr-old
grandson.
Communication:
English
Religion:
Muslim
Values &
Beliefs: Pt pray
before and after
each meal and at
bedtime- he
requested no
interruptions.
Ethnicity:
AfricanAmerican
Socioeconomic
status and social
class: lowincome, patient
is a construction
Evaluation Of Goals
Nursing Dx #3
Acute Pain
r/t
left knee
surgical
incision
As Evidence
By
1.verbal reports
of pain
2. grimacing
3.moaning,
4. guarding of
left hip and leg
area when
assessed and
dressing
changes.
5. P:
movements
Q: aching
R: localized
S: 6/10
T: starts when
he moves or
attempts to
move (PT) and
ends when he
rests, stops
from moving or
is given the
prescribed pain
Rationale
1.
Robust pain assessment is imperative to
ensure that patients receive safe and effective
pain management that is tailored to their
needs. Pain assessment is fundamental in
assisting the diagnosis of the cause of the pain
and it should not be assumed that this is selfevident.
Cardiff University. (2010). Pain Community
Centre. Retrieved May 06, 2016.
worker, primary
provider for his
5-year-old
grandson and
disable wife.
Patient state I
needs to get
back to work
and back to
normal activities
as soon as
possible because
I am the only
provider in the
house.
medications
Objective:
VS
Temp-98.8
Pulse-108
BP-160/85
RR-26
O2 Sat-97% on
4L NC
Pain Level- 6/10
. P: movements
Q: aching
R: localized
S: 6/10
T: starts when
he moves or
attempts to
move (PT) and
ends when he
rests, stops from
2. Nonverbal
indicators of pain
including
grimacing and
moaning will be
absent/diminishe
d within 30
minutes
2.
Monitor patients
vital signs for signs of
pain including:
increased heart rate,
blood pressure, and
respiratory rate every
two hours.
Observe patient for
nonverbal indicators of
pain including: facial
grimacing, moaning,
guarding, and crying
during assessment of
pain and vital signs.
Encourage
verbalization of
moving or is
given the
prescribed pain
medications.
-grimacing
-moaning
-guarding of left
hip and leg area
when assessed
and dressing
changes.
Labs:
Not applicable
Medications:
-Tramadol
(Ultram) 50mg
po Q6hrs
-Celecoxib
(Celebrex)
200mg po
Q12hrs
-Morphine
2mg/ml Q4hr
prn IV (Hold if
RR < 14)
-Oxycodoneacetaminophen
5/325 Q4hr po
prn
-Docusate
Sodium (Colace)
100mg po 2x
Daily
Medicate before an
activity (PT) to increase
patient participation.
3. Patient will be
able to his basic
ADLs and
activities within 6
weeks.
Provide assistance
with mobility while
ambulating with
prescribed cane or
walker.
Assess to what
degree cultural,
environmental,
intrapersonal, and
intrapsychic factors
may contribute to pain
or pain relief.
Instruct the patient to
evaluate and report the
effectiveness of
measures used.
Infective
Breathing
Pattern
Assessment
Subjective
Pt stated: I
started to have
difficulty
breathing after
my surgical
procedure 4/28.
Patient states:
After my
surgery I feel
like a pressure
on my chest
when I breath
Cultural/
Psychosocial
Background:
Patient married
for 40 years, 3
children and one
5-yr-old
grandson.
Communication:
English
Religion:
Nursing Dx #1
Ineffective
Breathing
Pattern
r/t
decrease rate
and depth of
respirations
associated with
the effect of
anesthesia
As evidence
by
1.Patient states:
After my
surgery I feel
like a pressure
on my chest
when I breath
2.Tachypnea
3Ddyspnea
4.Elevated B/P
5.Observed
physical
discomfort
6.Use of
accessory
Giving the
prescribed nursing
care the patient
will have a
controlled baseline
respiration rate
and a normal O2
saturation level.
As evidence by:
1.Establish a
normal/effective
respiratory
pattern
Nursing Interventions
6 per goal=18
Rationale
Assess respiratory
rate and depth by
listening to lung
sounds. Place a
monitor on patient
Assess accessory
muscles used for
breathing
(sternocleidomastoid,
scalene) and
retractions/flaring of
nostrils
Goals
Evaluation
Short Term:
Goal met, the
patient has
demonstrated
appropriate coping
behaviors and
methods to improve
breathing pattern.
Long term:
Muslim
Values &
Beliefs: Pt pray
before and after
each meal and at
bedtime- he
requested no
interruptions.
Ethnicity:
AfricanAmerican
Socioeconomic
status and social
class: lowincome, patient
is a construction
worker, primary
provider for his
5-year-old
grandson and
disable wife.
Patient state I
needs to get
back to work
and back to
normal activities
as soon as
possible because
I am the only
provider in the
house.
Objective:
-Tachypnea- RR
26
Muscle noted
7.Nasal Flaring
8.O2 Sat of
97% with O2
4L via Nasal
cannula
9.hypoxia
2.Patient will
demonstrate
appropriate
coping behaviors
like proper
breathing and
coughing
Teach client
appropriate deep
breathing and coughing
techniques
Teach patient side
effects of medications
that he is taking
(morphine, Oxycodone)
Maximize respiratory
effort with good
posture and effective
use if accessory
muscles.
-dyspnea
-elevated B/P
160/85
-Observed
physical
discomfort
- Use of
accessory
Muscle noted
-Nasal Flaring
- O2 Sat of 97%
with O2 4L via
Nasal cannula
-hypoxia
Labs:
-BUN-34
-Creatinine3.010
-HhA1c- 7.2
-Glucose- 398
-ABGs
pH-7.26
PaCO2-56
HCO3-24
[Respiratory
Acidosis/ Acute
Ventilation
Failure-Respiratory
Depression
(Anesthesia)]
Medications:
Not applicable
Reassess ABG
levels, according to
facility policy, to
monitor oxygenation
and ventilation status.
Auscultate breath
sounds at least every 4
hours to detect
decreased or
adventitious breath
sounds; report any
changes.
3.Patient would
be able to apply
techniques that
would improve
breathing pattern
and be free from
signs and
symptoms of
respiratory
distress.
Assist patient to a
comfortable position,
such as by supporting
upper extremities with
pillows, providing
over- bed table with a
pillow to lean on, and
elevating head of bed.
periods of rest
Assessment
Activity
Intolerance
(SOB)
Subjective:
Patient state: I
feel weak and
fatigued every
time I try to do
any exercise or
activity, during
physical therapy
my leg really
hurt and I feel
Short of Breath
Cultural/
Psychosocial
Background:
Patient married
for 40 years, 3
children and one
5-yr-old
grandson.
Communication:
English
Religion:
Muslim
Values &
Beliefs: Pt pray
before and after
each meal and at
bedtime- he
Dx#2
Interventions
Rationale
Evaluation of Goals
Establish Rapport
1.After 2 days of
nursing
interventions the
client exhibited a
normal range of
respiratory pattern
of 20, cardiac rate of
79 bpm and has no
shortness of breath
and fatigue during
any activity
Goals
Activity
intolerance
r/t
-the presence
of surgical
incision
-imbalance
between
oxygen demand
as manifested
by
1.limited
mobility on the
lower
extremities
2. Shortness of
breath
3.Elevated
Heart Rate
-108
4.Fatigue
5.Obesity 151.3
Kg
6. Patient
States: Pain
6/10
7. Patient states
I fell fatigued
and week every
1.After 2 days of
nursing
interventions the
client will be able
to maintain
activity level
within
capabilities, as
evidenced by
normal heart rate
during activity,
as well as absence
of shortness of
breath, weakness,
and fatigue.
Short Term:
Encourage patient to
have adequate bed rest
and sleep
Assist the client in
ambulation
requested no
interruptions.
Ethnicity:
AfricanAmerican
Socioeconomic
status and social
class: lowincome, patient
is a construction
worker, primary
provider for his
5-year-old
grandson and
disable wife.
Patient state I
needs to get
back to work
and back to
normal activities
as soon as
possible because
I am the only
provider in the
house. Patient
state multiple
times that he
will love to
return home to
play baseball
with his
grandson.
Objective:
-Facial grimace
time I have to
do any
activities
8. Increase of
baseline B/P
with activities168/90- 164/88
9. Elevated
Respiration
Rate - >26
Note presence of
factors that could
contribute to fatigue
Ascertain clients
ability to stand and
move about and degree
of assistance needed or
use of equipment
Give client information
that provides evidence
of daily or weekly
progress
Encourage the client to
maintain a positive
attitude
Assist the client in a
semi-fowlers position
to prevent injuries
when moved
VS:
-T: 98.8
-P: 108
-RR: >26
-BP: 168/90
-164/88
Pain scale of 8
out of 10 with
movement or
exercise
-Burning
sensation on
incision site
-Guarded
movement
-Limited
mobility in
lower
extremities
Morse Fall
Scale= 85 High
risk -Risk fall
prevention
interventions
Braden Scale=
20 Low risk of
developing
pressure ulcers.
Physical
therapy 4xDaily
Establish rapport
Monitor vital signs
Establish guidelines
and goals of activity
with the patient and
caregiver.
Encourage adequate
rest periods, especially
before meals, other
ADLs, exercise
sessions, and
ambulation.
Encourage
verbalization of
feelings regarding
limitations
Maintain a quiet,
comfortable
environment
Teach
patient/caregivers to
recognize signs of
physical over activity.
Teach energy
conservation
techniques.