ASSESSMENTOFMULTIPLEPATHOLOGYPATIENT

INWARD4B
SRINAGARINDHOSPITALKHONKAENTHAILAND
A. HEALTHHISTORY
1. ClientProfile
Mr.Sis87yearsold.Heliveswithhiswifeandhischildren.
2. Chiefcomplain:
Fever,coughanddyspneaforoneday
3. PresentIllness:
6 days ago, the patient had high fever, coughing without sputum, no sore
throat,nodifficultyinurinary,drowsiness.
Onedayago,thepatienthadfever,cough,secretionsoundinthethroatand
dyspnea,sohewassenttoSrinagarindHospital.
MedicalDiagnosis:CAP,Respiratoryfailure,UrineTractInfection,DMtype
II,OldCVA,AcuteKidneyInjury,Sepsis.
4. PastIllnesses
- DiabetesmellitusandHypertensionalmost20yearsago(onmedication)
- OldCVA,leftfacepalsy,lefthemiparesissince12yearsago
- Goutsince9yearsago
- Dyslipidemia9years
- IHD
Homemedication
- ISDN
- Isordil
- Colchicine
- Plavix
- Simvastatin
- VitaminB6
- Folicacid
B. GENERALAPPEARANCE
Bloodpressureis137/72mmHg,Pulseis112times/minute,Respirationrate27
times/minute,37,0C.Thepatientlooksweakness,lookspale,nojaundice,the
patientonlylyingonthebed.
C. GENERALPHYSICALASSESSMENT
1. Assessmentofskin,hairandnails
Skin:thepatientskiniswhite,temperaturefeelswarmon2upperandlower
extremities, the turgor skin is not elastic. Skin of patient is dry. Hair:

patientshairiswhitelookscleananddry.Nails:fingernailsshort,thickand
clear.
2. AssessmentofHeadandNeck
Headsymmetricallyround,neckwithfullroom,andnontender,noscars,
massesorpulsation.Tracheamidline.
3. AssessmentofEyeandEar
Eye:patientdoesnotuseglassestosee.Nodiagnosedblindness.Theretina
issimilarandequalsize.Noswelling,redness,orthickness.Butpatients
conjunctivaisanemic.
Ear:Coloroftheskinearconsistentwithcolorofskinonface.Nolumpsor
lesions.Nontenderbilateral.Thepatientdoesnotusetooltohear.
4. AssessmentofNoseandSinuses
Nasalseptum:midlinewithoutbleedingofperforation,noinflammationon
skinlesion.Frontalandmaxillarysinusesisnontenderbilateral.
5. AssessmentofMouthandPharynx
Donotfindanyproblemsinmouthandpharynx,patientslipsisdry,nutno
lesionorulcerations.Nomasses aroundpatientsmouth.Tonguemidline
whenprotruded,nomassesorlesions.Nocoughing.
6. AssessmentofHeart
Bloodpressure:137/72mmHg,S1,S2sound,thereisnomurmur.
7. AssessmentofPeripheralVascularSystem
Arms:equalinsizeandsymmetry,palpablepulseisnotweak
Legs:equalinsizeandsymmetry.Thepatientscanmovehislegs.
8. AssessmentofThoraxandLung
Novisiblepulsationorlesionpresent.ThepatientCanbreathbyhimself
without nasal, no coughing, no crepitation, there is no secretion sound.
Patient looks uncomfortable when breathing. Patient uses of accessory
muscle.
9. AssessmentofGenitourinary
Patientusescatheterization.
10. AssessmentofMusculoskeletal
Patientonlylyingonthebad,hecannotwalkcauseofweakness.
11. AssessmentofNeurological
PatienthasoldCVA,leftfacepalsy,since12yearsago

12. AssessmentofExtremity
Patienthashemiparesisontheleftlowerandupperside.
D. FANCAS(Fluid,Aeration,Nutrition,Activity,Stimulation)
1. Fluid
Patientcannotdrinkbyhimself. Patienthasdehydration,skinandmucous
aredry.urine coloris dark yellow,BUN =24,3mg/dl,Cr= 0,9mg/dl,
Potassium3,1mEq/l,Phosphorus1,0mg/dl.
2. Aeration
- PatientbreathingissupportbyventilatorCPAPPS10,PEEP5,FiO2
0,4.
- pH7,47,pCO231,4mmHg,pO286mmHg.
- SaturationO295%,I:E1:3
- Respiratoryrate27times/minute,
- Capillaryrefill<3second
3. Nutrition
- Thepatientcannoteatbyhimmouth
- Thepatientshasstartfeeding,lipsandskinaredry.
- OnIVFdx5%,Ns80cc/hours.
4. Communication
- Patientcannotmakecommunicationwithotherpeople.
- PatientonCPAPandETTube.
- Patienthasdementiaanddelirium
- Patientwasrestrained
- Patientcanresponsetovoice
5. Activity
- Thepatientisonlylyingonthebedwithoutactivity.
- HeissemicomaandPressuresore
6. Stimulation
- Patientisconscious
- Patienthasreflectandresponse.GCSE=4,M=T,V6
- Patientcanresponsepainstimulus.

7. SupportedAssessment
a.Laboratory(ClinicalChemistry)

No. Test
1
2
3
4
5
6
7
8
9
10
11

25/02/201
6
24,3
0,9

145
3,7
23,4
105
7,7
0,8
2,4
227

BUN
Cr
Uric
Na
K
HCO3
Cl:
Ca
Po4
Alb
Blood
Sugar

Normal
5,819,1mg/dL
0,51,5mg/dL
2,77,0mg/dL
130147mEq/L
3,44,7mEq/L
20,628,2mEq/L
96107mEq/L
8,410,2mEq/L
2,54,6mEq/L
3,85,4g/dL
72to108mg/dL

Interpretatio
n
High
Normal

Normal
Normal
Normal
Normal
Low
Low
Low
High

b.RoutineHematology
No. Test
1

Hb

25/02/201
6
12,3

2
3

Hct
Wbc

37,9
16900

4
5
6
7
8
9

Plt
PMN
Lympho
Mono
Eos
Baso

150k
87,8
4,7
7,3
0
0,2

Normal
M13,517,5
mg/dL,
M4054%
4000
10.000/mm3

Interpretatio
n
Low
Low
Infection

2035%
28%
14%
01%

c.ArterialBloodGas
No. Test

Value

Interpretation

pH

pCO2

7,411
Normal
(N:7,357,45)
31,4mmHg(N Low
:32,048,0)

Clinical
implication

PaCO2
impairment can
occur

in
hypoxia,anxiety
/ nervousness
and pulmonary
embolism .
Values less than
20 mmHg need
to get a special

closeattention.
3

pO2
sO2

4
5

ctHb

Hct

86 mmHg N: Normal
(83108)
95% (N: 95 Normal
99%)
12,4g/dl
Low
(N: M 13,5
17,5,F 12,0
15,5)
36

d.Medication
No.
Nameofmedicines
1
Colchicine

Actions
Colchicine is a medication most
commonlyusedtotreatgout
Plavix is used to prevent blood
clotsafterarecentheartattackor
stroke, and in people with certain
disorders of the heart or blood
vessels.

Plavix

Colistin

Colistin(polymyxin E) is
apolymyxinantibioticproducedby
certain strains ofPaenibacillus
polymyxavar.colistinus. Colistin
is a mixture ofcyclic
polypeptidescolistin A and B.
Colistin is effective against
mostGramnegativebacilli and is
usedasapolypeptideantibiotic.

Meropenam

Meropenemis an ultrabroad
spectrum injectableantibioticused
totreatawidevarietyofinfections

Metronidazole

Metronidazoleisreducedtodisrupt
energymetabolismofanaerobesby
hindering the replication,
transcriptionandrepairprocessof
DNAresultsincelldeath

Actrapid

InsulinHormone

e.SputumCulture
No.
1

Findings
Klebsiellapneumonia

Coagulate

staphylococci

Definitions
Is a gram negative, non motile,
encapsulated, lactose fermenting,
facultative anaerobic, rodshaped
bacterium.
positive Is a genus of gram positive
bacteria. Under the microscope,
theyappearround(cocci),andform
ingrapelikecluster.

DATAANALYZE
NO
1

DATA

SD:
OD:
- Dyspnea
- Respirationrate27times/minute
- ThepatientonCPAPPS10,PEEP5,FiO20,4,SaturationO295%,I:E1:3
- SputumCulture:Klebsiellapneumonia,Coagulatepositivestaphylococci.
- pH:7,411
- pCO2:31,4mmHg
- PO2:86mmHg
- Patientlooksuncomfortablewhenbreathing.
- Patientusesofaccessorymuscles

ETIOLOGY
Inflammation lung tissue
(Pneumonia)

PROBLEM
Ineffectivebreathingpattern

SD:
OD:
- Delirium
- Patientlooklyingonthebedcauseofweakness
- Capillaryrefill<3second
- pH:7,411
- pCO2:31,4mmHg
- PO2:86mmHg
- Dyspnea

Ineffectivelungfunction

Risk for ineffective tissue

perfusion

SD:
OD:

Septicemia, pneumonia, and

UTI

Riskforsepticshock

137/72mmHg,Pulseis112times/minute,Respirationrate27times/minute,37,0C.
Delirium
SputumCulture:Klebsiellapneumonia,Coagulatepositivestaphylococci
Hct37,9%
Wbc16900/mm3
Patientlookspale

SD:
OD:
- NPO
- Lipsandskinaredry
- Delirium
- BUN:24,3
- Ca77mEq/L(Low)
- Alb2,4g/dL(Low)
- Sodium:145mEq/L
- Potassium:3,7mEq/L
- Cl:105mEq/L
- Ca:7,7mEq/L

Decreasekidneyfunction

Risk for fluid and electrolyte

imbalance

SD:
OD:
- Bloodsugarlevel:227mg/dL
- Thepatientlooksweakness

Hyperglycemiaandlowimmune

Riskforinfection

137/72mmHg,Pulseis112times/minute,Respirationrate27times/minute,37,0C.

SD:
OD:
- Thepatientlyingonthebed
- ThepatientonETTube
- Thepatientusecatheterization.
- PatientonIVFD5%
- 137/72mmHg,Pulseis112times/minute,Respirationrate27times/minute,37,0C.

Immobilization and invasive Riskforcomplication

procedure,
tissue
destruction

SD:
OD:
- Thepatientcannoteatbyhimmouth
- Thepatientshasstartfeeding,lipsandskinaredry.
- OnIVFdx5%,Ns80cc/hours.
- Hb12,3
SD:
OD:
- Thepatientonlylyingonthebed
- Patientcannotmeettobathandhygiene
Thepatientisweaknessandwasrestrained

CriticalillnessandNPO

Riskforimpairednutrition

Semicomaanddelirium

Selfcaredeficit

NursingDiagnosis:
1. Ineffectivebreathingpatternrelatedtopneumoniaandsemicoma
2. Riskfortissuehypoxiarelatedtopneumoniaandineffectivelungfunction
3. Riskforsepticshockrelatedtosepticemia,pneumonia,andUTI.
4. Riskforfluidandelectrolyteimbalancerelatedtodecreasekidneyfunction

5.
6.
7.
8.

Riskforinfectionrelatedtohyperglycemia
Riskforcomplicationrelatedtoimmobilization
RiskforimpairednutritionrelatedtocriticalillnessandNPO
Selfcaredeficitrelatedtosemicomaanddelirium

NURSINGINTERVENTION
NURSING DIAGNOSIS
ANDDATAANALYZE
1. Ineffective breathing
pattern related to
pneumoniaandsemicoma.

SD:

PURPOSE/ RESULT NURSING

RATIONALE
EVALUATION
CRITERIA
INTERVENTION
NOC:
1. Assess and record 1. To detect early signs of respiratory 1. Patientsrespiratoryrateremains
respiratory rate and depth
compromise. Also assess ABG levels,
withinestablishedlimits.
Respiratorystatusventilation
atleastevery4hours.
accordingtofacilitypolicy,tomonitor
2.
Patients ABG levels return to
Withresultcriteria
2. Auscultatebreathsoundsat
oxygenationandventilationstatus.
and remain within established
- Nodyspnea

OD:
-

Dyspnea
Respiration rate 27
times/minute
ThepatientonCPAP
PS10,PEEP5,FiO 2
0,4, Saturation O2
95%,I:E1:3
Sputum Culture:
Klebsiella
pneumonia,
Coagulate positive
staphylococci.
pH:7,411
pCO2:31,4mmHg
PO2:86mmHg
Patient

looks
uncomfortable when
breathing.
Patient uses of
accessorymuscles

leastevery4hours.
Respiratoryratenormal
The patient doesnt use 3. Assist patient to a
comfortable position, such
canola/ ET tube/
as by supporting upper
ventilator
extremities with pillows,
Patient will report
providing over bed table
feeling comfortable
with a pillow to lean on,
whenbreathing
andelevatingheadofbed.
Arterial blood gas 4. HelppatientwithADLs,as
(ABG)levelswillreturn
needed.
tobaseline
5. Administer oxygen as
ordered.
6. Suctionairwayasneeded.
7. Schedule

necessary
activities to provide
periodsofrest.
8. Teach patient about:
pursed lip breathing,
abdominal breathing,
performing relaxation
techniques,

taking
prescribed medications
(ensuringaccuracyofdose
and frequency and
monitoring

adverse
effects),

scheduling
activities to avoid fatigue
and provide for rest
periods.
9. Referpatientforevaluation
of exercise potential and

2. To detect decreased or adventitious

breathsounds;reportchanges.
3. Thesemeasurespromotecomfort,chest
expansion, and ventilation of basilar
lungfields.
4. To conserve energy and avoid
overexertionandfatigue.
5. Supplemental oxygen helps reduce
hypoxemia and relieve respiratory
distress.
6. Retained secretions alter the ventilator
response,thusreducingoxygen,leading
tohypoxemia.
7. This prevents fatigue and reduces
oxygendemands.
8. These measures allow patient to
participateinmaintaininghealthstatus
andimproveventilation.
9. Exercise promotes conditioning of
respiratorymusclesandpatientssense
ofwellbeing.

limits.
3. Patient indicates, either verbally
or through behavior, feeling
comfortablewhenbreathing.
4. Patientreportsfeelingrestedeach
day.
5. Patient performs diaphragmatic
pursedlipbreathing.
6. Patient demonstrates maximum
lung expansion with adequate
ventilation.
7. When patient carries out ADLs,
breathingpatternremainsnormal.

development

of
individualized exercise
program.
2. Risk for tissue hypoxia
related to Ineffective lung
function

SD:
OD:
-

Delirium
Patient look lying on
the bed cause of
weakness
Capillary refill <3
second
pH:7,411
pCO2:31,4mmHg
PO2:86mmHg
Dyspnea

NOC:
Tissue does not occur
hypoxia,
Withresultcriteria:
- Vitalsignwithinnormal
- Blood Gas within
normal
- Thepatientconscious
- Thepatientslookfresh
- capillary refill still < 3
second

1. Monitor respiratory rate,

depth,andeffort,including
use of accessory muscles,
nasalflaring,andabnormal
breathingpatterns.
2. Auscultatebreathsounds.
3. Monitor client's behavior
andmentalstatusforonset
of restlessness, agitation,
confusion,and(inthelate
stages)extremelethargy.
4. Monitor oxygen saturation
continuously, using pulse
oximeter.
5. Observe for cyanosis in
skin; especiallynote color
oftongueandoralmucous
membranes.
6. If client is acutely
dyspneic, coach the client
to slow respiratory rate
using touch on the
shoulder, demonstrating
slower respirations while
making eye contact with
the client, and
communicating in a calm,

1. Increased respiratory rate, use of

accessory muscles, nasal flaring,
abdominal breathing, and a look of
panicintheclient'seyesmaybeseen
withhypoxia
2. Presenceofcracklesandwheezesmay
alertthenursetoanairwayobstruction,
which may lead to or exacerbate
existinghypoxia.
3. Changesinbehaviorandmentalstatus
can be early signs of impaired gas
exchange(Misasi,Keyes,1994).Inlate
stages the client becomes lethargic,
somnolent,andthencomatose(Pierson,
2000).
4. Note blood gas results as available.
Anoxygensaturationof<90%(normal:
95%to100%)orapartialpressureof
oxygen of <80 (normal: 80 to 100)
indicates significant oxygenation
problems.
5. Central cyanosis of tongue and oral
mucosaisindicativeofserioushypoxia
andisamedicalemergency.Peripheral

1. Nottheappearanceofsignsand
symptomsthatleadtothetissue
hypoxia.
2. Demonstrates

improved
ventilation and adequate
oxygenation as evidenced by
bloodgaseswithinclient'snormal
parameters
3. Maintains clear lung fields and
remains free of signs of
respiratorydistress
4. Verbalizes understanding of
oxygen and other therapeutic
interventions

supportivefashion.
cyanosisinextremitiesmayormaynot
7. Demonstrate

and
beserious(Carpenter,1993).
encouragetheclienttouse 6. Anxiety can exacerbate dyspnea,
pursedlipbreathing.
causing the client to enter into a
8. Positionclientwithheadof
dyspneic panic state (Gift, Moore,
bed elevated, in a semi
Soeken,1992;Brueraetal,2000).The
Fowler's position as
nurse'spresence,reassurance,andhelp
tolerated.
incontrollingtheclient'sbreathingcan
9. Maintainlowflowoxygen
therapy.
beverybeneficial(Truesdell,2000).
7. Pursedlipbreathingresultsinincreased
use of intercostal muscles, decreased
respiratoryrate,increasedtidalvolume,
andimprovedoxygensaturationlevels
(Breslin, 1992). Pursedlip breathing
can result in increased exercise
performance(Casciaraietal,1981),and
it empowers the client to selfmanage
dyspnicincidences(Truesdell,2000).
8. SemiFowler'spositionallowsincreased
lung expansion because the abdominal
contentsarenotcrowdingthelungs.
9. An elderly client is susceptible to
oxygeninducedrespiratorydepression.
3. Risk for septic shock
related to Septicemia,
pneumonia, and UTI, low
immune.

NOC
1. Monitorvitalsigns,routine 1. Tofindoutthestatuschangesthatlead 1. Nottheappearanceofsignsand
totheonsetofsepticshocksymptoms
symptoms that lead to the
Septic shock status is not
hematologyandbloodgas.
2.
The

Urine

color

that

is

one

of

septic
presenceofsepticshock.
2. Monitorintakeoutput.
appear
shocksymptomsandinfections.
2.
Showedadecreaseininfection
3. Identify and remove the
Withresultcriteria:

SD:
OD:
-

137/72 mmHg, Pulse

is 112 times/minute,
Respiration rate 27
times/minute,37,0C.
Sputum Culture:
Klebsiellapneumonia,
Coagulate positive
staphylococci
Hct37,9%
Wbc16900/mm3
SIRScriteria:Sepsis

4. Risk for fluid and

electrolyte imbalance
relatedtoDecreasekidney
function

SD:
OD:
-

NPO
Lipsandskinaredry
Delirium
BUN:24,3
Ca77mEq/L(Low)
Sodium:145mEq/L
Potassium:3,7mEq/L
Cl:105mEq/L

sourceofinfection
4. Provideoxygentherapy
5. Keep giving liquids are
given directly into a vein
(intravenous)
6. Monitorresultculture
7. Collaboration

in
maintaining antibiotics
(Metrodinazole,
Meropenam,NextTime)

3. Toovercomeinfection
4. Tomaintainrespiratorystatus
5. Tomaintainstableperformanceofthe
heart and avoid an increase in blood
concentration
6. Toovercomeinfection

3. Vitalsignswithinnormal
4. laboratory tests of blood within
normal
5. showed no change in mental
statusawareness
6. Patientawareness

NOC
1. Monitorvitalsigns
Demonstrate stabilized fluid 2. Monitor for abnormal
serum electrolytes, BUN,
volume as evidenced by
andCreatinin.
balancedI&O
3. Monitorformanifestations
Objective:
ofelectrolyteimbalance
Maintain fluid and 4. Maintain accurate intake
electrolytebalance.
andoutputrecord
Withresultcriteria:
5. Administer supplemental
- vital signs within
electrolytes(e.g.,oral,NG,
patientsnormalrange
and IV) as prescribed, if
- stable weight, and
appropriate. IVFD 5%DX,
absence of signs of
N/280cc/hours.
edema.

1. Tofindoutthestatuschanges
2. It serves as an initial effort to assess
fluidstatusandelectrolytes,andcanbe
used as an early indicator in
determiningthenextofactions.
3. It serves as an initial effort to assess
fluidstatusandelectrolytes,andcanbe
used as an early indicator in
determiningthenextofactions.
4. Itservestoavoidtheconditionsoffluid
andelectrolyteimbalance.
5. Anattemptpreventivinmaintainingof
adequacyfluidandelectrolyte.

Theclientremainsinastateoffluid
andelectrolytebalancelevelswithout
signs of lack of fluids and
electrolytes.

Vital signs within

normal
laboratorytestsofblood
withinnormal
Notindicatedconfusion
orchangedstatusmental
Not indicated skin rash
ordiscoloration

Ca:7,7mEq/L
Intakeoutput???

5.Riskforinfectionrelated
to low immune, DM with
poorcontrol.

SD:
OD:
-

Blood sugar level:

227mg/dL
The patient looks
weakness
137/72 mmHg, Pulse
is 112 times/minute,
Respiration rate 27
times/minute,37,0C.
HbA1c7,5
Pressure sore 3 area
grade2
Catheterization and
ETTube.

6. Risk for complication

relatedtoImmobilization

Electrolyte still in
normalvalues

NOC
Prevent infection and
promoteimmunestatus.
- ImmuneStatus
- Riskcontrol
Withcriteriaresult:
- Blood sugar level
withinnormal
- Notappearancesignsof
infection

from
Catheterization,
pressure sore, IVF, ET
Tube.
- Vital signs within
normal.
- HbA1cwithin68.

1. Assess signs and

symptoms of infection
especiallytemperature.
2. Emphasize the importance
ofhandwashingtechnique.
3. Maintainaseptictechnique
whencaringwound.
4. Emphasized necessity of
taking antibiotics as
ordered.
5. Clean up the environment
afteruseofotherpatients
6. Limit visitors when
necessary
7. Instruct visitors to wash
their hands when visiting
andaftervisiting
8. Collaboration for insulin
injection.

1. Fevermayindicateinfection.
2. It serves as a first line of defense
againstinfection.
3. Wetareacanbelodgeareaofbacteria
4. Prematurediscontinuationoftreatment
when client begins to feel well may
resultinreturnofinfection.
5. It serves as a first line of defense
againstinfection.
6. It serves as a first line of defense
againstinfection.
7. It serves as a first line of defense
againstinfection.

Patientwasfreefromanysignsand
symptomsofinfectionsasmanifested
byabsenceoffever.

NOC
1. Observeandreportsignsof 1. Withtheonsetofinfectiontheimmune 1. Remains free fromsymptomsof
Objection:
infection such as redness,
infection
system is activated and signs of
Prevent Complication and
warmth, discharge, and
2.
States symptoms of infection of
infectionappear.

SD:
OD:
-

The patient lying on

thebed
PatientonIVFD5%
137/72 mmHg, Pulse
is 112 times/minute,
Respiration rate 27
times/minute,37,0C.
Pressure sore 3 areas
gradeII.
Patientwasrestrained

promote

mobilization

Withcriteriaresult:
- Remains

free
fromsymptomsof
complicationinfection
- Vital signs within
normal
- NoPressuresoreandin
otherareas
- Nojointstiffness
- Nolungsinfiltration.
- Grade of pressure sore
sameorbetter.
- Burden scale score 18
(Normal)
- Muscle power same or
better.

2.
3.

4.

5.
6.
7.

8.
9.

increased

body
temperature.
Promotemobilizationsuch
asPassiveROMandmove
positionevery2hours.
Assess temperature of
neutropenicclientsevery4
hours; report a single
temperatureof>38.5Cor
threetemperaturesof>38
Cin24hours.
Noteandreportlaboratory
values (e.g.,white blood
cellcount and differential,
serum protein, serum
albumin,andcultures).
Assess of pressure sore
(Skinintegrity,moisture)
Maintainfoodnutrition.
Carefullywashandpatdry
skin, including skinfold
areas. Use hydration and
moisturization on all at
risksurfaces.
Encourageabalanceddiet,
emphasizing proteins to
feedtheimmunesystem.
Use strategies to
preventnosocomial
pneumonia: assess lung
sounds, sputum, and

2. Neutropenic clients do not produce an

whichtobeaware
adequate inflammatory response; 3. Demonstratesappropriatecareof
infectionpronesite
therefore fever is usually the first and
4. Maintainswhitebloodcellcount
oftentheonlysignofinfection(Wujcik,
and differential within normal
1993).
limits
3. When temperature values have 5. Demonstrates

appropriate
important consequences for treatment
hygienic measures such as hand
decisions, use mercury or electronic
washing, oral care, and perineal
care
thermometerswithestablishedaccuracy
(Ericksonetal,1996).
4. Laboratory values are correlated with
client's history and physical
examinationtoprovideaglobalviewof
the client's immune function and
nutritional status and develop an
appropriate plan of care for the
diagnosis(Lehmann,1991).
5. Preventive skin assessment protocol,
includingdocumentation,assistsinthe
prevention of skin breakdown. Intact
skin is nature's first line of defense
against microorganisms entering the
body(Kovach,1995).
6. Maintaining supple, moist skin is the
bestmethodofkeepingskinintact.Dry
skin can lead to inflammation,
excoriations, and possible infection

rednessordrainagearound
stoma sites; use sterile
waterratherthantapwater
for mouth care of
immunosuppressed clients;
provide a clean manual
resuscitation bag for each
client;usesteriletechnique
when suctioning; suction
secretions above tracheal
tube before suctioning;
drain

accumulated
condensation in ventilator
tubinginto afluidtrapor
other collection device
before repositioning the
client; assess patency and
placement of nasogastric
tubes; elevate the head of
theclientto(30toprevent
gastricrefluxoforganisms
in the lung; institute
feeding as soon as
possible;assessforsignsof
feeding intoleranceno
bowel sounds, abdominal
distension, increased
residual,emesis.
10. Encouragefluidintake.
11. Encourageadequaterestto
bolstertheimmunesystem.

7.

8.

9.

10.

11.

episodes (Kovach, 1995) (seeRisk for

impairedSkinintegrity).
Immunefunctionisaffectedbyprotein
intake(especiallyarginine);thebalance
between omega6 and omega3 fatty
acid intake; and adequate amounts of
vitaminsA,C,andEandtheminerals
zinc and iron. A deficiency of these
nutrientsputstheclientatanincreased
riskofinfection(Lehmann,1991).
Hospitalacquired pneumonia is the
second most common nosocomial
infection but has the highest mortality
(30%) and morbidity rates. The
strategies listed are used to prevent
nosocomial pneumonia (Tasota et al,
1998).Once treatment for pneumonia
hasbegun,itmustcontinuefor48to72
hours,theminimumtimetoevaluatea
clinicalresponse(Ruizetal,2000).
Fluid intake helps thin secretions and
replace fluid lost during fever
(Carlianno,1999).
Chronic disease and physical and
emotional stress increase the client's
needforrest(Potter,Perry,1993).
Consistent and meticulous hand
washing remains the most important

7. Risk for impaired

nutritionrelatedtocritical

NOC
Objective:

12. Use proper hand washing

contributingfactorrelatedtoreduction
techniquesbeforeandafter
of the frequency of nosocomial
giving care to client and
infections in the intensive care unit
any time hands become
(ICU). Hand washing significantly
soiled, even if gloves are
decreases the number of pathogens on
worn: Wet hands under
theskinandcontributestodecreasesin
running water; dispense a
client'smorbidityandmortality(Tasota
minimum of 3 to5ml of
soap or detergent and
et al, 1998). Ensure that all hospital
thoroughly distribute it
staff members follow precautions to
over all areas of both
preventthespreadofinfection.Inthis
hands;vigorouslywashall
study,ahighpercentageofstaffdidnot
surfaces of hands and
wash hands at appropriate times
fingersforatleast10to15
(Chandra,Milind,2001).Whensoapis
seconds,includingbacksof
used,themechanicalactionofwashing
hands and fingers and
under nails; rinse to
and drying removes most of the
remove soap, and
transientbacteria.Handsshouldremain
thoroughly dry hands; use
in contact with the cleanser for 10
a dry paper towel to turn
seconds,but20to30secondsisideal
the faucet off.
(Gould,

1994a).
Rinsing hands with tap
wateranddryingthemwith
towels can reduce
methicillinresistantStaphy
lococcus aureus(MRSA)
contamination by 95%
(SarverSteffensen,1999).
1. Assess for proteinenergy 1. Clientsininstitutionsaresusceptibleto 1. Nutritionalstatuswithinnormal
malnutrition.
proteincalorie malnutrition (PCM) or 2. Thereisnodecreasebodyweight
2. Interpret

laboratory
3. Caneatbyhimself

illnessandNPO

SD:
OD:
-

Thepatientcannoteat
byhimself
Thepatientshasstart
feeding,lipsandskin
aredry.
On IVF dx5%, Ns
80cc/hours.

Hb12,3
Alb2,6.

8. Self caredeficit related

toSemicomaanddelirium

PromoteGoodnutrition

findingscautiously
3. Offer high protein
supplements based on
Intake of nutrients
individual needs and
insufficient meet to
capabilities
metabolicneeds
4. Offer liquid energy
Withresultcriteria
supplements
- Nutritionalstatus
5. Instruct in wise use of
- Thepatientcaneat
supplements.
- Nutrientintake
6. Consider the effects of
medicationsonfoodintake
7. Provide appropriate food
textures for chewing ease.
Insertdentures(ifneeded)
beforemeals.Assessfitof
dentures. Refer for dental
consultation if needed.
Thebonystructureofjaws
changes over time,
requiring adjustment of
dentures.

NOC
Objection:

2.

3.
4.

5.

6.
7.

proteinenergy malnutrition when they 4. Intakeandoutputbalance

areunabletofeedthemselves.
Compromised kidney function makes
reliance on urine samples for nutrient
analyseslessreliableintheelderlythan
inyoungerpersons.
The supplement is then served as a
medicine.
Energy supplementation has been
shown to produce weight gain and
reducefallsinfrailelderlylivinginthe
community.
Milkalkali syndrome has occurred in
womeningesting4to12gofcalcium
carbonatedaily(Beall,Scofield,1995).
Appetitestimulatingdrugsmayhavea
roleinsomecases.
The most common feeding difficulties
among geriatric rehabilitation clients
involveddentures(lackoforillfitting)
and oral infections (Keller, 1997).

1. Assess client's ability to 1. Use of observation of function and

bathe self through direct
report of function provide

1. Remainsfreeofbodyodorand
maintainsintactskin

SD:
OD:

Maintain self care

activities

Thepatientonlylying
onthebed
- Patientcannotmeetto
bathandhygiene
- The patient is
weakness and was
restrained
COMBINE.

ClientOutcomes
- Good hygiene, good
smell.
- Lookcleanandfresh.
- NosignsofIAD.

2.

3.

4.

5.

observation (in usual

bathingsettingonly)and
from client/caregiver
report, noting specific
deficitsandtheircauses.
If in a typical bathing
setting for the client,
assess via direct
observation

using
physical performance
testsforADLs.
Ask client for input on
bathing habits and
cultural

bathing
preferences.
Develop a bathing care
plan based on client's
own history of bathing
practices that addresses
skin needs, selfcare
needs, client response to
bathing and equipment
needs.
Individualize bathing by
identifying function of
bath (e.g., odor or urine
removal), frequency
required to achieve
function,andbestbathing
form(e.g.,towelbathing,
tub, or shower) to meet

2.

3.

4.

5.

complementaryassessmentdataforgoal
andinterventionplanning(Reubenetal,
1992).
Observationofbathingperformedinan
atypical bathing setting may result in
false data for which use of a physical
performance test compensates to
provide more accurate ability data
(Guralnik,1994).
Creating opportunities for guiding
personal care honors longstanding
routines, increases control, prevents
learnedhelplessness,andpreservesself
esteem (Miller, 1997). Cultural
preferences are respected (Freeman,
1997).
Bathingisahealingriteandshouldnot
be routinely scheduled with a task
focus. It should be a comforting
experiencefortheclientthatenhances
health. (Rader, Hoeffer, McKenzie,
1996).
Individualizedbathingproducesamore
positive bathing experience and
preserves client dignity. Client
aggression is increased with shower
(especially) and tub bathing. Towel

2. States satisfaction with ability

touseadaptivedevicestobathe
3. Bathes with assistance of
caregiver as needed without
anxiety
4. Explains and uses methods to
bathe safely and with minimal
difficulty

6.
7.

8.

9.

client

preferences,
preserve client dignity,
make bathing a soothing
experience, and reduce
clientaggression.
Request referrals for
occupationalandphysical
therapy.
Planactivitiestoprevent
fatigue during bathing
and seat client with feet
supported.
Consider environmental
and human factors that
maylimitbathingability,
such as bending to get
into tub, reaching
required for bathing
items, grasping force
needed for faucets, and
lifting of self. Adapt
environment by placing
items within easy reach,
lowering faucets, and
usingahandheldshower.
Use any necessary
adaptive

bathing
equipment (e.g., long
handled brushes, soap
onarope, washcloth
mitt,wallbars,tubbench,

6.

7.
8.

9.

10.

bathingincreasesprivacyandeliminates
needtomoveclienttocentralbathing
area; therefore it is a more soothing
experiencethaneithershoweringortub
bathing (Rader, Hoeffer, McKenzie
1996;Hoefferetal,1997;Miller,1997).
Collaboration and correlation of
activities with interdisciplinary team
membersincreasestheclient'smastery
of selfcare tasks (Schemm, Gitlin,
1998).
Energy conservation increases activity
toleranceandpromotesselfcare.
Environmental factors affect task
performance.
Function can be improved based on
engineering principles that adapt
environmental factors to the meet the
client'scapabilities(Rogersetal,1998).
Adaptive devices extend the client's
reach, increase speed and safety, and
decreaseexertion.
Theclientperceiveslessprivacyifmore
than one caregiver participates or if
bathingtakesplaceinacentralbathing
area in a hightraffic location that
allowsstafftoenterfreelyduringcare
(Miller,1994).

10.

11.
12.

13.
14.
15.

shower chair, commode

chair without pan in
shower).
Provide privacy: have
only one caregiver
providing

bathing
assistance, encourage a
trafficfree bathing area,
andpostprivacysigns.
Keep client warmly
covered.
Allow client to
participate as able in
bathing. Smile and
provide praise for
accomplishments in a
relaxedmanner.
Inspect skin condition
duringbathing.
Use or encourage
caregiver to use an
unhurried,caringtouch.
Ifclientisbathingalone,
placeassistancecalllight
within

reach.

11. Clients, especially elderly clients, who

are prone to hypothermia may
experience evaporative cooling during
and after bathing, which produces an
unpleasant cold sensation (Miller,
1994).
12. The client's expenditure of energy
provides the caregiver the opportunity
toconveyrespectforawelldonetask,
whichincreasestheclient'sselfesteem.
Smiling and being relaxed are
associatedwithacalm,functionalclient
response(Maxfieldetal,1996).
13. Observationofskinallowsdetectionof
skinproblems.
14. Thebasichumanneedoftouchoffers
reassuranceandcomfort.
15. A readily available signaling device
promotes safety and provides
reassurancefortheclient.