Patient statements of:
“I don’t change positions very two hours.”
“I feel phlegm in my chest but I can’t cough
it all up.”
Nonblanchable redness on coccyx.
Crackles heard in bilateral lower lobes.
Impaired tissue integrity
Ineffective airway clearance
Report any altered sensation or pain at
sire of tissue impairment during every assessment until discharge.
Patient will maintain a patent airway until
site with every assessment for color changes, redness, swelling, warmth, pain, or
other signs of infection. Determine whether the patient is experiencing any changes
in sensation or pain.
EBP: Can identify
impending problems early (Ackley and Ladwig, pg.
sounds every 4 hours.
of adventitious breath sounds indicates what is wrong (Ackley and Ladwig, pg. 125.)
Patient reports no change in pain or sensation with both 0800 and 1200 assessments
and agrees to continue to report any changes for the length of stay.
O2 saturation at the 1200 assessment was 93%
Patient’s airway is patent. No report of difficulty or pain with breathing.
Site monitored with every assessment; no changes have been noted. Oncoming shift
will continue monitoring site.
, oncoming shift will continue to monitor O2 saturation. Crackles still present
in lower lobes.
mechanical force of pressure
Patient will demonstrate understanding of
plan to heal tissue and prevent injury by the end of 1200 assessment on [date].
demonstrate effective coughing by the end of 1200 assessment on [date].
Work with the patient to devise and implement
a written treatment plan for topical treatment of the skin impairment site.
EBP: Ensures consistency in care and documentation
(Ackley and Ladwig, pg. 840).
Teach the client to turn every two hours
and to avoid laying on the site of impaired tissue integrity.
EBP: Used to fully avoid adverse effects
of external mechanical forces (Ackley and Ladwig, pg. 841).
Help patient to cough and deep breathe and
perform controlled coughing.
EBP: uses diaphragmatic muscles. Cough is
more forceful and effective (Ackley and Ladwig, pg. 125 and 126).
Patient seems excited to have a role in determining the treatment
of his impaired tissue. At the end of the 1200 assessment, he vocalized that he
will change positions every two hours and understand that the nurse on each shift
will apply a protective cream to his coccyx every shift.
Patient has been coughing and deep breathing every hour but
with little mucous production.
Patient admits that he hasn’t been turning every two hours
at the end of the 1200 assessment. Additional teaching will be provided to him and
amount of turning will be reassessed after the 1600 assessment. Protective cream
applied at the end of each skin assessment.
Teaching has been implemented. Assess lung sounds every shift
and document any changes.