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Care Map 2

Care Map 2

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Published by Linda Kuglarz

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Published by: Linda Kuglarz on Oct 12, 2008
Copyright:Attribution Non-commercial

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06/16/2009

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INTERVENTIONS:
ENSURE THAT OXYGEN DELIVERY SYSTEM IS APPLIED TO THEPATIENT- THE APPROPRIATE AMOUNT OF OXYGEN ISCONTINUOUSLY DELIVERED SO THAT THE PT DOES NOTDESATURATE.AN OXYGEN SATURATION OF 90% OR GREATER SHOULD BEMAINTAINED. THIS PROVIDES FOR ADEQUATE OXYGENATION.ENCOURAGE DEEP BREATHING & COUGHING EXERCISES.POSITION PT FOR OPTIMAL BREATHING PATTERN- HOB >30DEGREES.MAINTAIN A CLEAR AIRWAY BY ENCOURAGING PT TO CLEAROWN SECRETIONS WITH EFFECTIVE COUGHING- IFSECRETIONS CAN NOT BE CLEARED, SUCTION AS NEEDED TOCLEAR SECRETIONS.PACE AND SCHEDULE ACTIVITIES PROVIDING ADEQUATE RESTPERIODS- THIS PREVENTS DYSPNEA RESULTING FROMFATIGUE.USE PAIN MANAGEMENT AS APPROPRIATE- THIS ALLOWS FORPAIN RELIEF AND THE ABILITY TO DEEP BREATHE.
GOALS:
PT WILL HAVE NO SOB ANDWILL MAINTAIN O2 SAT >90%W/ NC THROUGHOUT THESHIFT 7A-1P.
 
 
EVALUATION:
PT SHOWS NO S/S OF SOBSPO2 IS MAINTAINED AT 92%WITH 2L/MIN BY NCPT RESTING WELL IN CHAIR ATBEDSIDE AND CARRYING ON ACONVERSATION WITH HERCAREGIVER. NO COMPLAINSOF DISCOMFORT OR PAIN ATTHIS TIME.
NURSING DX 2:
ACTIVITYINTOLERANCE R/TIMBALANCE BETWEENOXYGEN SUPPLY ANDDEMAND AEB PT
 WEAKNESS DURINGWALKING TOWASHROOM
 
INTERVENTIONS:
ENCOURAGE ADEQUATE REST PERIODS, ESPECIALLY BEFORE MEALS,ADL’S, EXERCISE SESSIONS AND AMBULATION- REST BETWEENACTIVITIES PROVIDES TIME FOR ENERGY CONSERVATIONREFRAIN FROM PERFORMING NONESSENTIAL PROCEDURES- PT WITHLIMITED ACTIVITY TOLERANCE NEED TO PRIORITIZE TASKSANTICIPATE PT’S NEEDS- KEPP TELEPHONE AND TISSUES WITHIN REACHASSIST WITTH ADLS AS INDICATED- ASSISTING THE PT WITH ADLS ALLOWSFOR CONSERVATION OF ENERGY.PROVIDE BEDSIDE COMMODE AS INDICATED- THIS REDUCES ENERGYEXPENDITUREPROGRESS ACTIVITY GRADUALLY, AS WITH THE FOLLOWING: ACTIVE ROMIN BED, PROGRESSING TO SITTING AND STANDINGDANGLING 10 TO 15 MIN 3X DAILYDEEP BREATHING EXERCISES 3X DAILYSITTING UP IN CHAIR 30 MINUTES 3X DAILYWALKING IN ROOM 1 TO 2 MINUTES 3X DAILYWALKING IN HALL 25 FEET, THEN SLOWLY PROGRESSING, SAVINGENERGY FOR RETURN TRIP- THIS PREVENTS OVEREXERTING THE HEARTAND PROMOTES ATTAINMENT OF SHORT RANGE GOALS.IMPROVISE IN ADAPTING ADL EQUIPMENT OR ENVIRONMENT-APPROPRIATE AIDS WILL ENABLE PT TO ACHIEVE OPTIMALINDEPENDENCE FOR SELF- CARE.
 
GOALS:
PT WILL AMBULATE 15FT WITHOUT SOB BYTHE END OF THE SHIFT7A-1P
 
EVALUATION:
PATIENT TOLERATES WELL AMBULATINGTO THE WASHROOM (15FEET),AND ONTHE RETURN TRIP TO THE CHAIR. PTUSES WALKER AND CONTINUOUS O2 BYNC 2L/MIN TO AID IN AMBULATION ANDMOST OF THE ADLS THAT SHE DOES BYHERSELF: TEETH CLEANING, FACEHYGIENE, FEEDING AND TOILETING.

 
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NURSING DX 1:
INEFFECTIVEBREATHING PATTERNR/T HYPOXIA AEBLOW O2 SAT OF 90%AND SOB.

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