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Desired Outcomes

1. Fluid overload
The patient will maintains adequate fluid volume and
electrolyte balance as evidenced by vital signs within
normal limits, clear lung sounds, resolution of edema

Interventions
Fluid overload
1. Daily weight; monitor for a significant weight
change (2 lb.) in one day
2. Monitor and document vital signs
3. Auscultate lung sounds and assess for crackles in
lungs, change in respiratory pattern, shortness of
breath
4. Assess for presence of edema by palpating over
tibia, ankles, and feet
5. Strict I&O
6. Monitor chest x-ray reports
7. Evaluate urine output in response to diuretic
therapy

2. Risk for Infection-Pneumonia
The patient will display patent airway with breath
sounds clearing, absence of dyspnea, cyanosis

Risk for Infection-Pneumonia
1. Monitor V/S closely, especially Temp
2. Assess depth and rate of respiration and chest
movement
3. Observe skin color and capillary refill
4. Assess LOC, distress and irritability
5. Encourage elevated HOB
6. Encourage adequate rest
7. Administer antimicrobials as ordered

3. Pain
The patient will verbalizes adequate relief of pain

Pain
1.

2.
3.
4.
5.
6.
7.

Assess pain characteristics: quality (sharp,
burning, shooting), severity, location, onset,
duration
Administer narcotics, analgesics, and muscle
relaxants as needed
Assess patient’s expectations for pain relief
Evaluate the patient’s pain after medication
administration
Instruct patient to evaluate and report
effectiveness of measures used
Eliminate additional stressors or sources of
discomfort whenever possible
Provide rest periods to facilitate comfort, sleep,
and relaxation

4. Altered Nutrition/Fluid & Electrolyte Imbalance
The patient will receive adequate nutrients to meet
metabolic needs; normal BUN and serum albumin, Hct,
Hgb, and lymphocyte levels

Altered Nutrition/Fluid & Electrolyte Imbalance
1. Daily weight
2. Assess new lab values: electrolyte, H&H,
glucose
3. Assess for and report signs and symptoms of
fluid volume excess
4. Monitor for manifestations of electrolyte
imbalance
5. Monitor and document vital signs changes
6. Strict I&O
7. Administer diuretics as prescribed

5. Impaired Skin Integrity
The patient will maintain tissue integrity as evidenced
by absence of redness and irritation

Impaired Skin Integrity
1. Inspect the skin and wound drainage, tape and
tubing
2. Anchor all tubing securely to prevent excessive
movement of tubes against tissues
3. Maintain an adequate nutritional status of the
patient

4.
5.
6.
7.

Instruct and assist the patient to support the
involved area when moving
Instruct and assist client to splint abdominal
when coughing
Perform aseptic technique to prevent infection
Assist with wound care (wound vac dressing
change) as ordered

6. Activity Intolerance
The patient verbalizes an understanding of the need to
gradually increase activity based on testing, tolerance,
and symptoms.

Activity Intolerance
1. Assess patient’s level of mobility
2. Assess patient’s nutritional status
3. Assess for signs and symptoms of activity
intolerance
Statements of fatigue, or weakness;
dyspnea, chest pain, diaphoresis or dizziness
4. Implement measures to improve activity
tolerance
Organize nursing care to allow for periods
of uninterrupted rest; assist the patient with
self-care activities as needed; implement
measures to reduce discomfort
5. Assess need for ambulation aids such as a walker
or cane
6. Instruct the patient to report a decreased
tolerance for activity
7. Provide emotional support while increasing
activity. Promote a positive attitude regarding
abilities.

7. Anxiety
The patient will appear calm and describe a reduction in
the level of anxiety experienced.

Anxiety
1. Assess the patient for signs and symptoms of fear
and anxiety: verbalization of feeling anxious,
insomnia, restlessness, elevated blood pressure)
2. Orient the patient to environment, equipment,
and routines; explain the purpose of procedures
and nursing care
3. Determine how patient copes with anxiety
4. Encourage verbalization of fear and anxiety
5. Maintain a calm manner while interacting with
the patient
6. Establish a working relationship with the patient
through continuity of care
7. Assist the patient in developing anxiety-reducing
skills such as relaxation and deep breathing

8. Falls
The patient will not experience falls

Falls
1.
2.
3.
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5.
6.
7.

Keep the bed in low position with side rails up
when the patient is in bed
Instruct and assist the patient to rise and change
positions slowly in order to reduce dizziness
Encourage the patient to request assistance
whenever needed; call light within easy reach
Assist the patient to use ambulatory aides (e.g.
walker, cane)
Perform actions to restore fluid and electrolyte
Allow adequate time for ambulation
Keep floor free of clutter and wipe up spills
promptly

Evaluation
This step will be in narrative format and you should discuss how you will measure each of the desired outcomes and
whether the desired outcome was met, partially met, or not met