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Patient Data:

Patient Name: L,P Age: 70 Allergies: NKA

Diagnosis: Acute Dyspnea

Diet: Npo

MH: Pleural Effusion, Pneumonia, Leucocytosis

Vs:

T: 97.3 P: 94 regular R: 22 B/P: 100/68 Ox: 99% per 3 L nasal cannula

Accu: 157

Psychosocial: Ego integrity vs. Despair

Patient is immobile, has nasogastric feeding tube 50 ml/hr, Foley catheter 200ml,

Telemetry monitor.

Problem 1

Risk for Impaired Skin Integrity

r/t patients inability to turn herself in bed

Assessment

-Patient is lethargic and is confined to bed, with mild dementia.-Pale skin is cool to touch, elastic and dry, with exception of the back,

back of the head and gluteus where it is warm and moist, with a

healing, clean stage 2 pressure ulcer in the sacral areal, with no odor or drainage.

skin turgor < 3 seconds

-Mild edema in lower extremities 1+

-Foley catheter patent with no leakages

-Mattress and blankets under patient were dry.

Goal

Patient will maintain skin integrity by the end of shift,

as evidenced by intact skin and no new areas of local inflammation.

Plan

Promote healing and maintain intact skin,

from developing new pressure ulcers.

Nursing Intervention

-Patient unable to move or follow commands

after stimulated.

-Washed my hands and wore gloves

-Moved and reposition patient carefully

to prevent injury to skin

-Removed tape and dressing carefully and

-Inspected the ulcer for drainage color and odor

-Applied Xenaderm as prescribed

-Repositioned patient to the left side

-Performed range of motion and massaged skin

to promote venous return.

-Maintained turning schedule q2h

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Evaluation

Integrity was maintained on patients intact skin,

Patients back, back of the head and gluteal area

remained dry and warm to the touch.

No drainage, redness, or further break down on

patients sacral ulcer.

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Problem 2

Risk for aspiration

r/t reduce level of consciousness

Assessment

-Patient is lethargic and immobile

-R: 22 Ox: 99% P: 94 and regular

-Patient feeding tube patent and-Patient continues to sleep and shows no signs of

respiratory distress

Plan

Monitor NG tube for patency and position

Observe patient for signs of coughing and chocking.

Observe for signs of regurgitation

Nursing interventions

-Checked for placement of Ng tube by

drawing placing the stethoscope over theStomach and listened to a whooshing sound

as a bolus of air was injected.

-Patient cough several times throughout the

observation. Patient gag/coughing reflex remained intact.

-Observed the mouth and nares for signs of regurgitation,

no fluids or signs of tube feeding, or fluids coming returned

through the mouth or nose.

Pulse ox 100% by nasal cannula

Evaluation

-Patient did not choke throughout the shift

-Ng tube remained patent and in place

-Patient maintained a patent airway.

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Problem 3

Risk for disuse syndrome

r/t immobility

Assessment

R: 24 P 94 apical B/P: 100/64

Patient is bedridden

Pale nail beds

Upper/lower extremities cool and pale

Mild edema 2+ lower extremities

Weak bilateral pedal pulse P: 90

Patient unable to bend extremities at lib

Decreased muscle strength

Goal

Patient will improve range of motion

and maintain peripheral circulation

as evidenced by decreased resistance by muscles and joints.

Plan

Reposition patient q2h

Elevate head of bed

Lower the head of bed when patient is not feeding.

Perform passive range of motion q4h

Provide support to lower extremities

Nursing intervention

Repositioned patient q2h at 4pm, then at 6pm

Elevated the head of bed to 45 degrees at 7pmPerformed range of motion on all extremities

And elevated and supported the feet to improve circulation and decrease edema

Evaluation

Outcome met, patient range of motion improved

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Problem 4

Risk for falls

Assessment

Patient has dementia

Patient is 70 y/o

Unable to follow commands

Lethargic

Goal

-Follow implemented strategies that enhance

-Safety and fall prevention.

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Plan

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-Continue to follow implemented fall precautions

-Assess the environment in patients room that will

Increase the risk for falls.

Nursing intervention

-Encouraged patient to wake up patient did not

-Placed call light within patient reach

-Maintained and ensured signs are posted that identify that

that the patient is at risk for falls.

-Placed items used by patient within easy reach

-Used bed rails and lowered as need, but made sure

they were up 3x before leaving the room.

-Kept bed in lowest position

-Ensured lights were on after sundown.

Evaluation

At the end of the shift, patient did not fall

No injuries were sustained.