Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

Subjective:

Daughter reported patient exhibited “mood swings” and periods of “confusion.”  Client expressed she didn’t want to move “anymore than she has to.”

Hx of DM II, CAD

Objective:

Temp:  101.0

Basilar rales bilaterally

Elevated BP (145/86)

Elevated HR (110)

Client is in atrial fibrillation w/ rapid ventricular response

EKG findings of inferior infarction and left axis deviation

Decreased urine output (0 ml/10 hours)

Elevated potassium level of 5.3

Elevated BUN (41)

Elevated Creatinine (1.73)

2x3, 1 inch depth stage II ulceration on coccyx

Unstageable ulceration on right heal

Presence of multiple tears on upper extremities

Client is NPO

Elevated blood glucose (185)

Yellow sputum production

Post-CVA

Problem

Impaired gas exchange

Long Term:

Client will demonstrate improved ventilation and adequate oxygenation as evidenced by blood gas levels within normal parameters for this client by 09:00, [date].

-Assess nutritional status including serum albumin level and body mass index. Weight loss in a client with COPD ha a negative effect on the course of the disease; resulting in a loss of muscle mass and in the respiratory muscles which can lead to respiratory failure  (Celli & MacNee, 2004, pg).

-Help the client eat small frequent meals and use dietary supplements as necessary.  Having a BMI less than 21 has been associated with earlier mortality in patients with COPD  (Schols et. al, 1995)
-monitor patient’s blood gas levels

R/T

Alveolar-capillary membrane changes, ventilation-perfusion imbalance

Short Term:

Client will maintain clear lung fields and remain free of signs of respiratory distress by 12:30, today.

-Monitor respiratory rate, depth and effort.

-Monitor client’s behavior and mental status for the onset of restlessness.  Changes in a client’s mental status can be an early sign of impaired gas exchange  (Simmons & Simmons, 2004).

-Monitor client’s oxygen saturation continuously by pulse oximetry.  The goal of inpatient therapy for the client with COPD is to maintain the oxygen saturation greater than 90% and PaO2 at or above 80 mm Hg to maintain cellular oxygen  (Celli & MacNee, 2004)

-Position client in the semi-Fowler’s position.  Research indicates that the 45 degree position facilitates breathing and reduces the risk of pneumonia (Speelberg & Van Beers, 2003).

-Remind the client to breathe through his nose and not his mouth

AEB:

Altered BP outside of acceptable parameters, oliguria (0 ml/10 hr), dysrhythmias, altered respiratory rate (24), decreased Hgb (10.2), decreased albumin (2.0), bilateral lobar rales, 90% oxygenation status on room air