|
Assessment
2
|
Nursing DX/Clinical
Problem
1.95
|
Client Goals/Desired
Outcomes/Objectives
2
|
Nursing Interventions/Actions/Orders
and Rationale
2
|
*I
|
Evaluation
2
|
|
Subjective
Patient’s statement:
“I don’t restrict my fluid as much as I was instructed.”
“I get out of breath quickly without my oxygen.”
Objective
Cr- 4.03
Hgb- 9.4
Hct- 29.3
Cap Refill-
3 seconds
Diminished
breath sounds in bilateral lower lobes
|
Problem
Excess fluid volume
Ineffective tissue perfusion
|
Long Term:
Explain measures that can be taken to treat or prevent excess fluid volume by discharge.
Demonstrate adequate tissue perfusion until discharge.
|
Teach the importance of fluid and sodium restrictions.
EBP: Fluid
restriction will reduce myocardial workload and sodium restriction will promote
excretion of excess fluid (Ackley and Ladwig, pg. 377).
Check capillary refill
EBP: nail beds return to usual color within 2-3 seconds
(Ackley and Ladwig, pg. 845).
|
|
Goal not
met, progress made. At end of shift on [date], patient was able to explain the
importance of restricting fluid and sodium intake.
Goal not
met, patient’s capillary refill upon [date] AM assessment was 3 seconds.
|
Patient taught
and able to verbalize importance of fluid and sodium restrictions. [date] AM
assessment will include another teaching to assist patient in achieving goal.
Capillary
refill checked during AM assessment. 3 seconds indicates effective tissue perfusion
but is not ideal. Capillary refill will be reassessed with [date] AM assessment.
|
|
R/T
CHF and renal failure
decreased oxygen supply to the blood
|
Short Term:
Describe symptoms that indicate the need to consult with health care provider by
the end of [date] AM assessment.
By the end of the AM assessment on [date], patient will identify changes in lifestyle
needed to increase tissue perfusion.
|
Teach about signs and symptoms of both excess and deficient
fluid volume and when to call physician.
EBP: Fluid balance can change rapidly (Ackley and Ladwig,
pg. 378).
Keep the client warm and have the client wear socks and shoes
when mobile. DO NOT apply heat.
EBP: Maintains vasodilation and blood supply. Heat can damage
ischemic tissues (Ackley and Ladwig, pg. 345).
|
|
Goal met. Patient was able to correctly identify symptoms
that would indicate need to contact physician.
Goal met, patient was able to correctly identify lifestyle changes that need to be made in order
to promote optimal tissue perfusion.
|
Teaching took place after AM assessment, patient was able
to verbalize the signs and symptoms to nurse. Short term goal is to be re-evaluated
on [date].
Patient was given blankets, TED hose, and non skid socks.
Water temperature of bath water will be monitored to ensure that it is not hot enough
to damage tissue.
|