Problem # 1: Pain Management

General Goal: Patient will state pain is more tolerable

Predicted Behavioral Outcome Objective (s): The patient will report a decrease in pain for a
7 to a 4 on the day of care

Nursing Interventions Patient Responses

1. Assess the patient’s need for pain management  Patient will describe what type of pain they
have, where it is, and how much pain they are in
2. Use the distraction method with a movie or TV show  Patient will be distracted and not think
about pain
3. Administer ordered NSAIDs or pain medications to the patient Patient will report a decrease
in pain
4. Provide a relaxing environment  Patient will be less stressed and may be able to sleep to help
with pain

Evaluation of outcome objectives: patient stated pain was at a 2/10 on the day of care

Problem # 2: Risk for impaired gas exchange

General Goal: Patient will be able to breathe better
Predicted Behavioral Outcome Objective (s): The patient will have an SpO2 above 95% on
the day of care

Nursing Interventions Patient Responses

1. Help patient deep breathe and cough  increase sputum clearance and decrease cough.
2. Position patient’s bed in semi-fowlers position  This allows for more thoracic capacity and
increased lung expansion
3. Encourage patient to ambulate as tolerated  Ambulation stimulates increased lung expansion
and secretion clearance
4. Provide the patient with ordered oxygen if the SpO2 drops below 95%  increase gas exchange
and amount of oxygen is getting to the brain.
5. Encourage use of incentive spirometer  promotes deep inspiration and prevents atelectasis
6. Suction as necessary  Prevents airway obstruction.

Evaluation of outcome objectives: The patient’s SpO2 was at 98% on the day of care
Problem # 3: Risk for deficient fluid problem
General Goal: Patient will be properly hydrated
Predicted Behavioral Outcome Objective (s): The patient will show no signs of dehydration
such as concentrated urine, decreased skin turgor, decreased urine output, thirst,
hypotension, tachycardia

Nursing Interventions Patient Responses

1. Encourage the patient to drink fluids  patient will be more hydrated
2. Teach importance of oral hygiene  caring for a dry, sticky mouth can promote interest in
drinking
3. Only provide patient with one sheet  Prevent more fluid loss through perspiration
4. Encourage patient to eat  patient may be week and food will help increase their strength so
they can get the proper intake they need

Evaluation of outcome objectives: Patient shows no signs of dehydration on day of care

Problem # 4: Risk for infection

General Goal: Patient will show no signs of infection
Predicted Behavioral Outcome Objective (s): Patient remains free of infection, as evidenced
by normal vital signs and absence of signs and symptoms of infection.

Nursing Interventions Patient Responses

1. Demonstrate and encourage good handwashing  decreases the spread of bacteria
2. Encourage adequate rest balanced with moderate activity and adequate nutrition  helps with
the healing process
3. Limit visitors  decrease chance of getting outside infection
4. Administer ordered antibiotics  decrease any signs and symptoms of infection and prevent
any infection from coming

Evaluation of outcome objectives: Patient showed signs of infection due to pneumonia

Problem # 5: Knowledge deficit
General Goal: Patient and caregiver will understand diagnosis
Predicted Behavioral Outcome Objective (s): Patient and caregiver will verbalize
understanding of condition, disease process, and prognosis.

Nursing Interventions Patient Responses

1. Determine how much patient and caregiver know about HLH  will be able to know how much
needs to be taught based on the responses
2. Assess potential home care needs  patient can be more comfortable and be able to deal with
the sickness with the proper care and equipment
3. Identify signs and symptoms requiring notification of health care provider  Prompt evaluation
and timely intervention may prevent complications.
4. Provide information in written and verbal form  may be overwhelming at first so having it
written down can increase understanding
5. Stress importance of follow-up appointments and compliance with medications  patient will
be able to deal with symptoms better and may be able to treat disease
6. Instruct on medication administration  patient will receive better therapeutic effects if the
caregiver knows how to properly administer them.

Evaluation of outcome objectives: Patient and caregiver understood and verbalized the patient’s
condition and prognosis

Problem # 6: Caregiver role strain

General Goal: Caregiver will not be as stressed during day of care
Predicted Behavioral Outcome Objective (s): The caregiver will state they are satisfied with
their role

Nursing Interventions Patient Responses

1. Encourage other family members to help and relieve pressure on the caregiver  the patient
could receive better care if the family members take turns so everyone’s stress is decreased
2. Encourage caregiver to take time for themselves  if the caregiver is not well, they will not be
able to care for the patient
3. Show caregiver how to reduce stress  patient will receive more effective care if caregiver in
stress free
4. Encourage caregiver to participate in support groups  these groups can provide education and
a place to vent with others to reduce stress.

Evaluation of outcome objectives: The caregiver stated satisfaction with role

Problem # 7: Risk for bleeding
General Goal: Patient will remain free of uncontrolled bleeding
Predicted Behavioral Outcome Objective (s): Child’s risk for injury from possible bleeding is
decreased through the use of appropriate prophylactic measures
Nursing Interventions Patient Responses
1. Assess for any signs of bruising and bleeding  Check for bleeding around mouth to promptly
stop and prevent blood loss
2. Assess for prolonged bleeding with minor injuries  bleeding can be life threatening in those
with bleeding disorders and needs to be stopped immediately
3. Assess for any pain and swelling over the entire body.  Pain or swelling could be caused from
an internal bleed
4. Monitor hemoglobin and hematocrit levels.  Monitoring these levels will allow for prompt
intervention if bleeding occurs
5. Educate on bleeding precautions  patient will have a better understanding on how to prevent
bleeds.

Evaluation of outcome objectives: Patient showed no sign of bleeding on day of care

Problem # 8: Risk for impaired skin integrity

General Goal: Patient will show no signs on impaired skin integrity
Predicted Behavioral Outcome Objective (s): Patient’s skin remains intact, as evidenced by
the absence of redness and open wounds over body

Nursing Interventions Patient Responses

1. Encourage the patient to turn in bed every 2 hours  patient will not spend too much time on
one side of body
2. Encourage ambulation  ambulation takes the pressure off of the skin
3. Encourage adequate nutrition and hydration  Helps maintain skin moisture and skin turgor to
prevent wounds
4. Educate patients and caregivers about proper skin care  patients will be more involved if they
understand the importance
5. Educate patient on bruising precautions  this will increase the patients skin integrity and also
prevent bleeding

Evaluation of outcome objectives: Patient’s skin remained intact on day of care