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Problem # 1: hypoxia/ impaired gas exchange

General Goal: adequate oxygenation

Predicted Behavioral Outcome Objective (s): The patient will have a spo2 > 93% on the day of care.

Nursing Interventions Patient Responses

1. continuous pulse ox 1. spo2 ranged from 97-99% on doc

2. duoneb Q4H 2. spo2 ranged from 97-99% on doc
3. increase HOB >30 degrees 3. participates in coughing/deep
breathing
4. suction prn Qshift and prn 4. sputum is clear/ productive
cough
5. monitor abgs QD and prn 5. metabolic alkalosis (ph 7.42 pco2
42.3 hco3 26.9)
6. BL crackles, respirations 16-24
6. respiratory assessment Q2H 7. pt initiating 2-10 breaths more
7. reassess need for intubation QH than set rate (AC: fio2 40, tv 450,
peep 5, rate 14)
8. monitor for signs of oxygen toxicity 8. pao2 98.2 on doc
seen with fio2 >60% and pt was on
only 40% 9. AC: fio2 40, tv 450, peep 5, rate 14) 9. Pao2 98.2, spo2 ranged from 97-99% on doc

Evaluation of outcome objectives: - outcome met

Spo2 ranged from 97-99% on day of care.

Problem # 2: anemia
General Goal: adequate perfusion
Predicted Behavioral Outcome Objective (s):
The patient will have a hemoglobin greater than the prior day value of 6.5 on doc.

Nursing Interventions Patient Responses

1. monitor h&h and rbcs daily 1. hemoglobin 7.2 hematocrit 22.1 rbcs
not drawn
2. continuous pulse ox 2. spo2 ranged between 97-99%
3. monitor for activity intolerance 3. RR 16-24 and spo2 ranged 97-99%
4. assess for edema Q2H 4. BL upper extremity +2 pitting edema,
BL lower extremity +3 pitting edema
5. assess pulses Q2H 5. BL pedal pulses +1
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6. assess cap refill Q2H 6. cap refill <3 BL UE/LE

7. assess skin color Q2H 7. pallor generalized
8. assess skin temp Q2H 8. skin feels warm. axillary temp 98
9. assess urine, skin, sputum for bleeding 9. no assessment findings indicative
of bleeding
Evaluation of outcome objectives: - outcome met
The patient’s hemoglobin was 7.2 on doc.

Problem # 3: altered mental status

General Goal: increased level of consciousness
Predicted Behavioral Outcome Objective (s):
The patient will follow commands with sedation vacation on the day of care.

Nursing Interventions Patient Responses

1. assess neuro status during sedation vacation (versed). 1. follows commands on sedation vacation
2. reorient to surroundings prn 2. pt recognized visitor
3. monitor liver labs 3. alk phos 693 – hepatic encephalopathy
related to alcohol intoxication
4. communicate using simple directions 4. strong hand grasp BL, picks head off bed
5. reassess rass Q2H 5. rass -1
6. neuro assessment Q2H 6. PERRL, opens eyes to touch, follows
commands with sedation vacation
7. reassess gcs Q2H 7. eye opening: 4, verbal: 1 (intubated), motor: 6
8. safety precautions/ assess BL restraints 8. free of injury with tubes in place/
compliant with restraints
Evaluation of outcome objectives: - outcome met
Pt follows commands with sedation vacation on day of care.

Problem # 4: sepsis
General Goal: hemodynamically stable

Predicted Behavioral Outcome Objective (s): The patient will maintain an axillary temperature between 97-
99 on day of care.

Nursing Interventions Patient Responses

1. monitor wbc QD 1. wbc 12.8 on doc

2. monitor neutrophils 2. neutrophils 97% on doc
3. strict I&O 3. tpn 54ml/hr output 50-150ml/hr on doc
4. merrem 100mg in 100ml ivpb q8h 4. normal temp ranged 98-98.2
5. levaquin 750mg/150ml qd 5. normal temp ranged 98-98.2
6. monitor temp Q2H 6. 8am temp 98.2, 10am temp 98
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7. continuous monitoring bp/map left radial art line 7. map ranged from 65-70 on doc
8. titrate vasopressin and levophed for map >65 8. map ranged from 65-70 on doc
Evaluation of outcome objectives: - outcome met
Pt axillary temperature ranged from 98-98.2 on day of care.

Problem # 5: hypervolemia
General Goal: fluid balance
Predicted Behavioral Outcome Objective (s):
The patient will diurese a minimum of 50ml/hr on day of care.

Nursing Interventions Patient Responses

1. fluid restriction 1. cumulative fluid balance +2435

2. strict I&O 2. urine output 50-150ml/hr/ tpn 54ml/hr
3. albumin 25g IV 3. cumulative fluid balance (prior day) +2435.5
4. bumex .5mg iv push 4. diuresed 425ml on shift
5. assess for edema Q2H 5. BL upper extremity +2 pitting edema,
BL lower extremity +3 pitting
edema
6. auscultate lungs Q2H 6. BL crackles
7. assess pulses Q2H 7. BL +1 pedal pulses
8. monitor weight QD 8. weight on doc 81.6kg compared to prior day 81.9kg (went
down)
Evaluation of outcome objectives: - outcome met
The patient diuresed 50-150ml/hr on day of care.

Problem #6: peg tube fungal infection

General Goal: free of infection
Predicted Behavioral Outcome Objective (s): The patient will have < 30ml of drainage from peg tube on
day of care.

Nursing Interventions Patient Responses

1. eraxis 100mg in 130ml ivpb 1. peg tube continues to have purulent drainage/ odor
2. dressing change qshift or prn 2. soiled dressing with purulent drainage/odor
3. npo / no tube feed 3. no bm
4. assess bowel movements 4. no bm
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5. peg to drainage 5. 0ml drained

6. assess peg site 6. inflamed, purulent drainage with odor
7. assess wbc and neutrophils 7. wbc 12.8 and neutrophils 97%
8. assess bowel sounds 8. hyperactive bowel sounds
Evaluation of outcome objectives: - outcome met
The patient had 0ml of drainage from peg tube on day of care.

Problem # 7: nutrition less than body’s requirements

General Goal: adequate nutrition
Predicted Behavioral Outcome Objective (s):
The patient will have an albumin level >3.5 on day of care.

Nursing Interventions Patient Responses

1. monitor blood sugar Q4H 1. blood sugar 132 at 7am

2. TPN 54ml/hr left brachial PICC 2. total protein 6.6 and albumin 3.0 on doc
3. monitor bowel movements 3. last bowel movement unknown
4. monitor weight 4. pt weighs 6kg less than admitting weight
5. monitor bowel sounds 5. bowel sounds hyperactive
6. monitor total protein lab trends 6. total protein trended from 7.5 on
admission to 6.6 on doc
7. admin albumin and monitor albumin level 7. albumin 3.0 on doc
8. D5 prn for blood sugar <100 8. blood sugar 132
Evaluation of outcome objectives: - outcome not met
Patient’s albumin level was 3.0 on day of care.

Problem #8: ineffective coping

General Goal: adaptation to permanent lifestyle changes
Predicted Behavioral Outcome Objective (s):
The patient will have a RASS between 0- -2 on the day of care.

Nursing Interventions Patient Responses

1. family education/ encouragement to visit 1. pt recognizes visitor

2. monitor for nonverbal signs of stress 2. pt appears anxious and tearful
3. assess support system 3. unsupportive significant other who
also suffers from substance abuse
4. limit irritating stimuli 4. less anxious with door closed
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5. hourly rounding 5. pt appears anxious and tearful during QH rounding

6. family education 6. pt previously in denial of palliative care
7. lexapro 20mg qd 7. pt remains anxious

8. wellbutrin 50mg tid 8. pt remains displaying depression with tearfulness

9. assess RASS q2h 9. RASS -1 on doc
Evaluation of outcome objectives: - outcome not met
The patient had a RASS of -1 on day of care.

Problem: decreased cardiac output

General Goal: adequate tissue perfusion

Predicted Behavioral Outcome Objective (s):

The patient will have a map greater than 65 on day of care.

Nursing Interventions Patient Responses

1. assess pulses Q2H 1. BL pedal pulse +1, BL radial pulses +2

2. assess cap refill Q2H 2. cap refill <3 BL UE/LE
3. assess skin color Q2H 3. pallor generalized
4. assess skin temp Q2H 4. skin feels warm. axillary temp 98
5. record output QH 5. output 50-150ml/hr cloudy yellow sediment on doc
6. continuous monitoring bp/map left radial art line 7. map ranged from 65-70 on doc
7. titrate vasopressin and levophed for map >65 7. map ranged from 65-70 on doc
8. continuous ekg monitoring 8. Normal sinus rhythm
Evaluation of outcome objectives: - outcome met
The patient’s map ranged between 65 – 70 on day of care.