Desired Outcomes

Acute pain
1. Patient will report pain level of 3/10
or less by 3/21/15, which is three
days after discontinuing the
morphine PCA and starting the 72
hour Fentanyl patch.

Imbalanced Nutrition less than body

requirements
1. Patient will consume at least 75%
of breakfast, lunch, and dinner.
2. Patient will maintain his admission
weight of 141lbs through the
duration of his recovery, which
places him within the normal range
of BMI.

Impaired Gas Exchange

Interventions
Acute pain
1. Ask patient what his pain level is
and to describe the pain every hour,
and particularly prior, during, and
after routine care is given.
2. Pre-medicate patient with PRN
medications prior to giving care.
3. Assess effectiveness of pain
medication by monitoring pain
prior to and 1 hour after
administration.
4. Cluster care to minimize
unnecessary manipulation of the
spine (i.e. back dressing change,
bed bath, and peri-care should be
done together).
5. Monitor patient for side effects of
pain medication, such as lethargy
and respiratory depression.
6. Use adjunct therapy, such as music,
distraction, and imagery.
Imbalanced Nutrition less than body
requirements
1. Ensure a staff member is present for
at least 45 minutes to assist the
resident to eat, with minimal
distractions.
2. Offer the patient nutritious snacks
between meals.
3. Request a dietary consult to assess
nutritional status, body
requirements, and alternatives to
increase the patients caloric
consumption.
4. Provide good oral hygiene.
5. Request a dental consult to ensure
dentures are fitted properly and
secure.
6. Encourage patients family to bring
in food from home, in collaboration
with dietary consult.
7. Take daily weights in order to
evaluate that the patient is within a
normal BMI.
Impaired Gas Exchange

1. Patient oxygen saturation will

remain greater than 95%.
2. Patients respiratory rate will be
between 12-20 respirations/minute.
3. Patient will not display signs and
symptoms of respiratory distress,
such as use of accessory muscles,
shortness of breath, or tachypnea.

Fluid and Electrolyte Imbalance

1. Patients electrolytes will be within
normal range.
2. Patients fluid intake and output
will remain balanced.

Decreased Cardiac Output

1. Patients blood pressure will be within
120-150 systolic and 60-80 mmHg
diastolic, heart rate will be between 60-80,
and urine output will be at least 30mL/hr.

Anxiety
1. Patient will express a reduction in
his anxiety level.
2. Patient will take an active role in
his care.

1. Assess quality, rate, rhythm, and

effort of respirations.
2. Monitor for elevated heart rate or
blood pressure.
3. Auscultate lungs sounds for
decreased ventilation and/or
abnormal breath sounds.
4. Monitor oxygen saturation.
5. Assess patients level of
consciousness and monitor for
changes in mental status.
Fluid and Electrolyte Imbalance
1. Monitor strict I & O.
2. Monitor serum electrolyte levels.
3. Monitor blood pressure, and
administer anti-hypertensive
medication as prescribed.
4. Assess oral mucous membranes.
5. Monitor urine output for color and
clarity.
6. Monitor IV take.
Decreased Cardiac Output
1. Monitor pulse, respirations, and
blood pressure.
2. Administer scheduled metoprolol
100mg if systolic is greater than
100 and heart rate is greater than
60.
3. Monitor for fluid and electrolyte
imbalances.
4. Administer sennosides/docusate
sodium, and monitor bowel
movements to prevent constipation.
Anxiety
1. Assess the patients level of anxiety
by assessing for normal heart rate
and respirations.
2. Ask patient what activities help him
to relax and assist him in
integrating these activities into his
care.
3. Explain procedures to the patient in
simple language, prior to beginning.
4. Assess patients orientation
frequently, and re-orient him to
person, place, and time, as needed.

Skin Integrity
1. Patients chest tube insertion sites
will remain free from redness,
swelling, and increased pain, and
the tape burns will continue to heal,
with no evidence of reoccurrence.
2. Patients surgical incision to the
mid-back will remain free from
redness, swelling, and increased
pain.
3. Patients two decubitus ulcers to the
buttocks will continue to heal.

Constipation
1. Patient will have a bowel
movement every 1-2 days.

Impaired Physical Mobility

1. Patient will be an active participant in
performing ADLs when the chest tubes are
removed.

Risk for Infection

5. Allow patient to ask questions and

participate in his care.
6. Try to maintain a consistent daily
schedule for the patient. Allow
ample time throughout the day for
rest.
7. Administer PRN lorazepam
(Ativan) if patient is agitated.
Skin Integrity
1. Clean and apply new dressing to
bilateral chest tube insertion sites,
daily. Assess for impaired skin
integrity.
2. Clean and apply new dressing to
surgical incision to mid-back.
Assess for impaired skin integrity
and wound healing.
3. Clean decubitus ulcer sites to upper
buttocks and apply new Mepilex, as
needed.
4. Ensure patients nutrition and fluid
intake is adequate.
5. Reposition patient every two hours,
and elevate bony prominences, such
as the heels and elbows.
Constipation
1. Monitor fluid and electrolytes.
2. Encourage ambulation or frequent
repositioning while in bed.
3. Schedule a bowel schedule for the
patient after meals.
4. Administer sennosides/docusate
sodium, daily.
5. Consult dietary for alternatives to
increase fiber in the patients diet.
Impaired Physical Mobility
1. Assist the patient in passive and
active ROM exercises.
2. Evaluate the safety of the patients
environment by ensuring fall
precautions are followed (bed rails
up, floor is cleared of clutter,
frequently used items are within
reach, and call light is within reach.
3. Reposition patient every two hours.
Risk for Infection

1. Patient will be free from signs and

symptoms of infection, such as elevated
temperature, redness or swelling to skin,
and elevated WBC count.

1. Perform routine cleaning and

dressing changes to bilateral chest
tube sites, back incision, and
decubitus ulcers on buttocks.
2. Assist patient with thorough
bathing.
3. Assist patient with good oral
hygiene.
4. Monitor for signs of symptoms of
infection, such as elevated
temperature, changes to skin
integrity, and changes in mental
status.
5. Perform good Foley care by
washing area with soap and water
every shift and as needed,
preventing dependent loops in tube,
storing bag below bladder, and
monitoring amount, color, and
clarity of urine output.

Evaluation
To evaluate the patients pain tolerance, a pain assessment will need to be done
every hour and before providing care. On 3/17/15, the patient exhibited a high level of
pain while raising and lowering the head of the bed. That evening, the patient was started
on a 72 hour Fentanyl patch, which was in conjunction with three Lidoderm patches that
are applied to the back for 12 hours every day and morphine PCA that delivers 1mg/hour
with six 0.2mg boluses every hour. On 3/18/15, the PCA was discontinue, however the
patient is still allowed PRN morphine given orally or IVP. While providing care on
3/18/15, the patient exhibited a greater tolerance for pain. Further assessment will be
needed to see if this effect continues with the morphine PCA discontinued.
To evaluate the patients impaired nutrition, daily weights should be taken. Also,
accurate documentation of the patients intake will help to assess the patients appetite.
The RN should assess the integrity of the patients dentures and for risk for dysphagia. If
any impairment is noted, a dental and/or speech therapist consult should be done. This
will be an ongoing process that will require careful evaluation and patience by the staff
member assisting the patient.
To evaluate the patients risk for impaired gas exchange, the heart rate, respiratory
rate, blood pressure, and oxygen saturation should be assessed every shift. Thorough
auscultation of the lung sounds and heart will also be included. Currently, there is no
indication of impairment, however with the patients drug regiment of Lidoderm,
Fentanyl, and PRN morphine, frequent assessment should continue.
To evaluate the patients risk for fluid and electrolyte imbalance, serum
electrolytes should be evaluated routinely while the patient is on IV fluids. Assessment

of the patients mental status, heart rate, blood pressure, and skin integrity could also
anticipate imbalanced fluids and/or electrolytes. Strict I&O should be maintained, with
particular attention paid to the chest tube drainage and urine output.
To evaluate the patients cardiac output, the heart rate, respiratory rate, and blood
pressure should be closely monitored. The patient has a history of hypertension,
complete heart block, and has a pacemaker installed. He also has a scheduled dose of
metoprolol 100mg daily. Assess the patients apical heart rate and blood pressure prior to
administration.
The patient has exhibited episodes of delirium during his hospitalization, so his
mental status should be routinely evaluated. Inquire from the patient his level of anxiety
and ways that he might cope with it. During the patients recent episodes of restlessness,
Ativan was given with good results. Monitor the patients sleep pattern, and evaluate
whether the patient is receiving adequate rest through the night. Continue to monitor.
To evaluate the patients skin integrity, perform routine dressing changes and note
any changes to the wound (i.e. Is it healing, as expected?). Thus far, the treatment is
effective and should be continued.
To evaluate the patients bowel habits, monitor and document the patients bowel
movements. Assess the patients stool characteristics, such as amount, consistency, and
color. Evaluate if sennosides/docusate sodium is effective or if another medication
should be used.
To evaluate the patients impaired physical mobility, assess and document
tolerance to activities. Note whether the patient is active or passive in his care, and
whether any impairment is cognitive or physiological in nature. During physical

assessments, evaluate gross and fine motor strengths. This goal has not been met yet,
however I anticipate that once the chest tubes are removed, the patient will be better able
to assist in his own self-care. Continue to assess.
To evaluate the patients risk for infection, monitor temperature regularly. Assess
the bilateral chest tube insertion sites, back incision, and decubitus ulcers for redness,
swelling, or increased pain. Monitor urine output for amount, color, and clarity. Assess
patients mental status for any acute changes. Continue to monitor.

Discharge Plan/Patient Teaching

Prior to admission, the patient was living in an assisted living facility. While
there has not been discussion of long-term placement, the patient is expected to transfer
to another facility to continue his recovery. It was mentioned among the health care team
that although there currently isnt an open bed for the patient, the other facility has
expressed interest in welcoming the patient to their facility. Part of the requirement for
his admission, however, is that the PCA be discontinued prior to transfer. As of 3/18/15,
the patients oral and transdermal pain regiment has been modified, and the PCA has been
disconnected. The bilateral chest tubes are also expected to be discontinued - likely
before he is transferred.
I observed a strong family support system during my care. Although the patient is
widowed, his nephew serves as his power of attorney. Also present during the patients
stay was another nephew and the patients younger brother. The patient is an active
member of his Baptist church, and his minister stopped by on 3/18/15.
In regards to performing his activities of daily living (ADLs), the patient requires
extensive assistance. Prior to his admission, the patient was able to ambulate with a
walker. Although capable of some gross motor function in all extremities, his strength is
weak. He can assist in turning from side to side in bed, but requires total assistance in
bathing and perineal care. The patients fine motor skills are also impaired, so he also
needs total assistance in eating, performing oral care, and other basic modes of hygiene.
The patient has several areas of impaired skin integrity that will require continued
assessment and dressing changes. Currently, the bilateral chest tube insertion sites
require daily dressing changes. Each side shall be dressed with xeroform gauze around

the proximal catheter at the insertion site. A drainage gauze will then be placed on top of
this, followed by several 4x4 gauze to cover the surrounding area. Everything will be
secured with foam tape, ensuring the area is well-protected and the tubing is anchored
down. The surgical incision on the mid-back stretches approximately 10 inches from top
to bottom. There are currently stitches that are reinforced with steri-strips. The site will
need to be cleaned daily with alcohol pads and dressed with an ABD pad and paper tape.
The two decubitus ulcers on the upper buttocks shall be receive a new Mepilex dressing
every three days, or as needed (i.e. soiled with BM, losing adhesive). Only chucks shall
be used for incontinence no disposable briefs.
The patient and family shall be instructed on several areas of care prior to
discharge. The teachings will be provided in the form of oral instruction, accompanied
with written instructions with easy-to-read, step-by-step pictures. Physical demonstration
will be provided, and the patient and primary caregiver will be asked to repeat the
demonstration and/or instructions. Important factors to consider is that the patient was
previously in an assisted living facility, and will likely require much more extensive
assistance related to his current medical condition and recovery. This is related to his
physical immobility, side effects from his current pain management regiment, and
declining cognitive function. Topics to be included will be nutrition, pain management,
fall prevention, and skin integrity.