Nursing Outcomes and Interventions

Desired Outcomes Interventions

Infection:
1. Patient remains free of infection, as
evidenced by normal vital signs and
absence of purulent drainage from wounds,
incision, and tubes
2. Patient maintains blood glucose and
glycosolated emoglobin levels witin
defined target ranges
!. Patient remains comfortable, free of pain
Infection:
1. "ssess for redness, swelling, pain, and
purulent drainage from incisions
2. #onitor temperature
!. #aintain asepsis for wound care and I$
management
%. &as ands before and after contact and in
between procedures
'. "dminister antibiotics as ordered
(. #onitor blood glucose and )b"1c
*. "dminister insulin as ordered
Pain:
1. Patient reports satisfactory pain control at a
level less tan ! to % on a + to 1+ rating
scale
2. Patient uses parmacological and
nonparmacological pain,relief strategies
Pain:
1. "ssess pain , -uality, severity, location,
onset, duration, precipitating or relieving
factors
2. "dminister analgesics as ordered
!. .liminate stressors or sources of discomfort
/e.g.: ligt, noise0
%. Provide rest period to facilitate comfort,
sleep, and rela1ation
'. .valuate response to pain and medications
or terapeutics aimed at abolising or
relieving pain
Immobility:
1. Patient performs pysical activity
independently or witin limits of condition
2. Patient demonstrates use of adaptive
tecni2ues tat promote ambulation and
transferring
!. Patient is free of complications of
immobility, as evidenced by intact s3in,
absence of tromboplebitis, normal bowel
pattern, and clear breat sounds
Immobility:
1. .ncourage appropriate use of assistive
devices
2. "llow patient to perform tas3s at is own
rate
!. Provide a safe environment
%. Institute measures to prevent s3in
brea3down and tromboplebitis from
prolonged immobility
Desired Outcomes Interventions
.limination:
1. Patient passes soft, formed stool at a
fre2uency perceived as 4normal5 by te
patient
2. Patient is normovolemic as evidenced by
urinary output greater tan or e2ual to
!+m67r, balanced inta3e and output, stable
weigt, absence or reduction of edema,
eart rate less tan 1++beats7min, absence
of crac3les
.limination:
1. .ncourage fluid inta3e
2. .ncourage ig fiber diet
!. "dminister PPI8s and la1atives7stool
softeners as ordered
%. #onitor I9O
'. "dminister fluid and7diuretics as ordered
"ltered nutrition7:luid 9 electrolyte
imbalance:
1. Patient demonstrates appropriate selection
of meals or menu planning toward te goal
of weigt reduction
2. Patient will ave normal 3idney function as
evidenced by normal ;<N and creatinine
lab values
"ltered nutrition7:luid 9 electrolyte
imbalance:
1. "ssess ability to accurately identify
appropriate food portions
2. .ncourage appropriate diet /cardiac0
!. "dminister proper antibiotic as ordered
/specific to patient since ab1 caused acute
renal failure0
Impaired s3in integrity:
1. Patient8s s3in remains intact, as evidenced
by no redness over prominences and
capillary refill less tan ( seconds over
areas of redness.
2. Patient8s incision and I$ site will remain
free of infection
Impaired s3in integrity:
1. "ssess general condition of te s3in
2. =pecifically assess s3in over bony
prominences
!. "ssess patient8s ability to move, nutritional
status, and for any edema
%. .ncourage implementation of a turning
scedule
'. .ncourage ambulation