RMS week two

Assessment (Supporting data) Subjective:

Nursing Diagnosis (NANDA diagnostic statement)

Goals & Expected Outcomes (Realistic, timed, measurable)

Nursing Interventions (Strategies or actions for care) Rationale for interventions

Evaluation (Client’s response to nursing actions & progress toward achieving goals & outcomes)

 Pt will use pain rating

 Determine whether

According to chart, pt consistently c/o pain, often 10/10

Objective:

Hx includes multiple back surgeries, scoliosis, osteoarthritis

Chronic pain r/t skeletal deformities, therapeutic procedures, and nerve damage AEB frequent c/o unrelieved pain, and visible spinal deformity

scale to identify current pain level, determine “acceptable level” of pain during initial nursing assessment  Pt will function on acceptable ability level with minimal interference from pain and medication side effects during shift (if pain is above acceptable level, pt will take action that decreases pain or notify nurse)  Pt will be able to perform ADLs and ambulate in hall with adequate pain control during shift

the pt is experiencing pain at the time of initial assessment. If so, intervene at that time to provide pain relief. Assess and document the intensity, character, onset, duration, and aggravating and relieving factors of pain.  Ask the pt to describe past and current experiences with pain and the effectiveness of the methods used to manage the pain, including experiences with side effects, typical coping responses, and the way the pt expresses pain.  Assess and document the intensity of pain and discomfort after any known pain producing procedure

RMS week two

or activity, with each new report of pain, and at regular intervals.  If the pt is unable to report pain using pain rating scale, assess and document behaviors that might be indicative of pain (e.g., change in activity, loss of appetite, guarding, grimacing, moaning).  Assume that pain is present and treat accordingly in pts who have a pathological condition or are undergoing a procedure thought to be painful.  Determine the client's current medication use. Obtaining a complete history of medications the client is taking or has taken can help to prevent drug-drug interactions and toxicity problems that can occur when incompatible drugs

RMS week two

are combined or when allergies are present. The history will also provide the clinician with an understanding of what medications have been tried and were or were not effective in treating the client's pain  Establish ATC dosing and administer supplemental opioid doses as needed to keep pain ratings at or below the acceptable level  Ask pt to describe appetite, bowel elimination, and ability to rest and sleep. Administer medications and treatments to improve these functions. Always obtain a prescription for a peristaltic stimulant to prevent opioid-induced constipation.  Explain to the pt the pain management approach that has been ordered,

RMS week two

including therapies, medication administration, side effects, and complications.  Discuss the pt's fears of undertreated pain, addiction, and overdose.  In addition to the use of analgesics, support the pt's use of nonpharmacological methods to help control pain, such as physical therapy, group therapy, distraction, imagery, relaxation, massage, and application of heat and cold.
Assessment (Supporting data) Nursing Diagnosis (NANDA diagnostic statement) Goals & Expected Outcomes (Realistic, timed, measurable) Nursing Interventions (Strategies or actions for care) Rationale for interventions Evaluation (Client’s response to nursing actions & progress toward achieving goals & outcomes)

RMS week two

Subjective:

Objective:

Risk for Injury r/t abnormal blood profile; altered clotting factors; altered electrolytes, decreased hemoglobin, and altered mobility

 Pt will remain free of

injuries during her hospital stay  Pt will be able to explain methods to prevent injury at home 

Thoroughly orient the client to environment. Place call light within reach and show how to call for assistance; answer call light promptly. Keep pt’s room clear of hazards and keep her favorite items within reach. For an agitated pt, consider providing individualized music of the pt's choice. Calming music was shown to be effective in decreasing agitation in persons with dementia If the pt is extremely agitated, consider using a special safety bed that surrounds the client. Special beds can be an effective alternative to restraints and can help keep the client safe during periods of agitation Get a sitter, to stay with the pt to prevent the client

RMS week two

from accidentally falling or pulling out tubes. Place an injuryprone client in a room that is near the nurses' station. Such placement allows more frequent observation of the client. Help pts sit in a stable chair with armrests. Avoid use of wheelchairs and gerichairs except for transportation as needed. Pts are likely to fall when left in a wheelchair or geri-chair because they may stand up without locking the wheels or removing the footrests. Refer to physical therapy for strengthening exercises and gait training to increase mobility. Refer to occupational therapy for assistance with helping clients perform ADLs. Gait

RMS week two

training in physical therapy has been shown to effectively prevent falls

Assessment (Supporting data) Subjective:

Nursing Diagnosis (NANDA diagnostic statement)

Goals & Expected Outcomes (Realistic, timed, measurable)

Nursing Interventions (Strategies or actions for care) Rationale for interventions

Evaluation (Client’s response to nursing actions & progress toward achieving goals & outcomes)

anxiety

Objective:

HGB 90 HCT 25 Cre 1.3 BUN 26 Labile BP

Fluid volume excess r/t increased isotonic fluid retention AEB decreased hemoglobin and hematocrit, restlessness; anxiety; blood pressure changes and azotemia

Pt’s edema will not worsen, and she will remain free of effusion, anasarca  Pt will not gain weight during hospital stay  Pt will maintain clear lung sounds; no evidence of dyspnea or orthopnea  Pt will show no

 Monitor location and

extent of edema. Generalized edema (e.g., in the upper extremities and eyelids) is associated with decreased oncotic pressure as a result of nephrotic syndrome. Heart failure and renal failure are usually associated with dependent edema

RMS week two

jugular vein distention  Pt will remain free of restlessness, anxiety, or confusion

because of increased hydrostatic pressure; dependent edema will cause swelling in the legs and feet of ambulatory clients and the presacral region of clients on bed rest.  Monitor daily weight for sudden increases; use same scale and type of clothing at same time each day, preferably before breakfast. Body weight changes reflect changes in body fluid volume. Clinically it is extremely important to get an accurate body weight of a client with fluid imbalance  Monitor lung sounds for crackles, monitor respirations for effort, and determine the presence and severity of orthopnea. Pulmonary edema results from excessive shifting of fluid from the

RMS week two

vascular space into the pulmonary interstitial space and alveoli. Pulmonary edema can interfere with the oxygen/carbon dioxide exchange at the alveolar-capillary membrane resulting in dyspnea and orthopnea.  With head of bed elevated 30 to 45 degrees, monitor jugular veins for distention in the upright position Increased intravascular volume results in jugular vein distention, even in a client in the upright position  Monitor vital signs; note decreasing blood pressure, tachycardia, and tachypnea.  Monitor serum osmolality, serum sodium, BUN/creatinine ratio, and hematocrit for decreases. These are all measures of

RMS week two

concentration and will decrease (except in the presence of renal failure) with increased intravascular volume. In clients with renal failure, the BUN will increase because of decreased renal excretion.  Monitor intake and output; note trends reflecting decreasing urine output in relation to fluid intake. Accurately measuring intake and output is very important for the pt with fluid volume overload.  Monitor the pt's behavior for restlessness, anxiety, or confusion; use safety precautions if symptoms are present. When excess fluid volume compromises cardiac output, the client will experience cerebral tissue hypoxia, and the pt may

RMS week two

demonstrate restlessness and anxiety before any physiological alterations occur When the excess fluid volume results in hyponatremia, symptoms such as agitation, irritability, inappropriate behavior, confusion, and seizures may occur

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