Problem #1: Risk for ineffective airway clearance r/t presence of artificial airway as evidenced

by increased respiratory rate (24) and need for suctioning

General Goal: Client will maintain a patent open airway and breathe effectively

Predicted Behavioral Outcome Objective (s): The patient will have normal breath sounds,
normal respiratory rate and depth, and mobilize secretions on the day of care.

Nursing Interventions:

1. Ensure tracheotomy is secured

2. Suction PRN
3. Encourage coughing up secretions
4. Auscultate lungs for adventitious breath sounds
5. Assess respiratory rate, depth, and pattern
6. Assess patient for signs of respiratory distress
7. Monitor ABG's and O2 saturation
8. Position pt. upright (no greater than 30 degrees d/t spinal fractures

Patient Responses:

1. Pt. will effectively breathe through tracheotomy

2. Pt. will have normal lung sounds, improved oxygenation, and less distress
3. Pt. will mobilize secretions
4. Pt. will have clear, normal lung sounds
5. Pt. will have normal RR, depth, and pattern
6. Pt. will not display any signs of respiratory distress
7. Pt. will have normal ABG's and O2 saturation greater than 93%
8. Pt. will have decreased work of breathing

Evaluation of Outcome: Outcome not met, the pt. had diminished breath sounds, periodically
increased respiratory rates, and needed suctioning

Problem #2: Trauma r/t recent fall as evidenced by spinal/rib fractures, and central cord
syndrome

General Goal: Prevent further injury/trauma r/t patient's spinal FX's and spinal cord injury

Predicted Behavioral Outcome Objective (s): Pt. will maintain stabilization of spine

Nursing Interventions:

1. Ensure cervical collar is positioned properly and secure

 2. Use adequate assistance when turning the pt. to maintain alignment of the spine
3. Monitor X-Rays and CT's r/t patients injuries
4. Educate patient about importance of immobilizing the head and neck
5. Assess neck for edema and swelling
6. Keep patient supine with the head of the bed elevated no further than 30 degrees
7. Assess for motor recovery/improvement from central cord syndrome
8. Assess for worsening pain which may be indicative of worsened injury

Patient Responses:

1. The patients head and neck will be secured and immobilized

2. The patient will be turned without destabilizing the spine or head
3. The patients imaging results will show no further trauma/injury of the spine, ribs and
cord and may even show healing
4. The pt. will understand the importance of keeping his head and neck still (even if he can
currently only nod, his mobility may slowly return)
5. Pt. will not have increased swelling or edema in his neck
6. Pt. will remain properly positioned to promote healing/stability
7. Pt. will show improvement in motor function, likely in the feet first
8. Pt. pain will be controlled and will not worsen

Evaluation of Outcome: Outcome met, pt's spine/neck maintained stability for duration of shift

Problem #3: Acute Pain r/t physical injury/trauma and operative procedure

General Goal: To control the patients pain and promote comfort

Predicted Behavioral Outcome Objective (s): The Patient will have a CPOT score of less than 3

Nursing Interventions:

1. Administer scheduled pain medications

2. Assess for presence of pain using CPOT scale (pt. is alert but nonverbal)
3. Assess for vital signs that may indicate pain such as increased BP and HR
4. Promote non-pharmacological pain management such as distraction
5. Immobilize the pts. head, neck, and spine to prevent increased pain from more injury
6. Administer PRN pain meds as indicated (scheduled meds. may not be adequate)
7. Evaluate effectiveness of pain medications after 1 hour of administration
8. Administer pain medication 30 minutes before turning pt.

Patient Responses:

1. Pts pain levels will be controlled and not increase

 2. Pt. will have a CPOT score of less than 3
3. Pt. will have a blood pressure and heart rate within normal range
4. Pt. will use non-pharmacological pain management methods to help reduce pain
5. Pts spine will remain stable, preventing further injury and worsening pain
6. Pt. will receive PRN pain meds. as indicated to reduce pain
7. Pt. will show a reduced pain score
8. Pt. will have less pain during turning or other nursing care

Evaluation of Outcome: Outcome met, pt. scored a 0 on the CPOT scale

Problem #4: Risk for imbalanced nutrition, less than body requirements r/t inability to ingest
food orally and alcoholism (malnutrition and empty calories, the pt. may have already been
malnourished and is at greater risk)

General Goal: Provide adequate nutrition

Predicted Behavioral Outcome Objective (s): Pt. will maintain a glucose level greater than 80,
maintain a normal albumin level, and maintain weight

Nursing Interventions:

1. Provide nutrition via tube feed as ordered

2. Assess clients weight daily
3. Assess patient's blood glucose levels
4. Assess lab values such as Albumin
5. Administer multivitamins and fluids as ordered
6. Assess bowel sounds
7. Check residual volume
8. Maintain head of bed elevation of 30 degrees, pause the tube feeding when turning or
lowering the head of bed

Patient Responses:

1. Pt. will tolerate the tube feed and receive nutrition

2. Pt. will maintain their weight during hospital stay
3. Pt. will maintain a normal blood glucose level
4. Pt's albumin levels will be in normal range
5. Pt. will remain hydrated and maintain normal electrolyte levels
6. Pt. will have normoactive bowel sounds
7. Pt will have a normal amount of residual volume
8. Pt. will not aspirate
Evaluation of Outcome: Outcome not met, pt's albumin level was low

Problem #5: Risk for infection r/t surgical wounds, tracheotomy/suctioning, foley catheter,
invasive lines, poor nutrition and decreased hemoglobin

General Goal: Prevent an infection from occurring and reduce risk

Predicted Behavioral Outcome Objective (s): Pt. will remain free from infection

Nursing Interventions:

1. Apply dressing changes when due for invasive lines and surgical wounds
2. Foam in and out of the room and wash hands as needed
3. Provide oral care Q 4 hours
4. Monitor labs that may indicate an infection such as elevated WBC
5. Assess for signs and symptoms of infection such as elevated temperature, swelling,
redness, etc.
6. Suction PRN to remove secretions and use clean technique when suctioning
7. Provide adequate nutrition (ensure tube feed is not paused longer than it needs to be,
administer vitamin supplements)
8. Assess urine for signs of infection, and clean the urethral area daily

Patient Response:

1. Pt's invasive line and surgical wound dressings will remain clean, dry and intact
2. Risk for transmission of infections is greatly reduced
3. Pt's mouth will remain clean, reducing infection risk
4. Pt's WBC will remain in normal range
5. Pt's temperature will be in normal range, and will not have any redness, swelling, etc.
around invasive line sites or surgical incisions
6. Pt will have reduced buildup of secretions
7. Pt. will have improved immune system response
8. Pt. will remain free from an UTI

Evaluation of Outcome: Outcome met, Pt. remained free from infection

Problem #6: Risk for impaired skin integrity r/t immobility, alteration in sensation, decreased
protein, inability to express discomfort, and incontinence
General Goal: Reduction and prevention of skin breakdown

Predicted Behavioral Outcome Objective (s): The patient will remain free from injury to the
dermis and epidermis for duration of care

Nursing Interventions:

1. Turn patient frequently (at least every two hours)

2. Change the position of the ETT (left, right, middle) frequently
3. Provide adequate nutrition to increase protein
4. Assess the skin for signs of injury such as redness, edema, pressure damage and
breakdown
5. Provide a bed bath daily
6. Clean the patient after episodes of incontinence and minimize exposure to moisture
7. Apply heelbo's to heels, and avoid letting bony prominences such as the knees contact
and rub each other
8. Apply measures to prevent the patient from sliding down in the bed (sliding down, and
frequently pulling up patients creates a risk for shearing)

Patient Responses:

1. Pt. will not have pressure injuries to the skin

2. Pt. will not have pressure injuries to the lips
3. The pt's protein level will increase, promoting healing
4. The pt. will not show any evidence of skin breakdown
5. The pt's skin will remain clean, smooth, and dry
6. The pt's skin will remain clean and free from feces or urine which can irritate the skin
7. The pt's bony prominences will remain free from tissue injury
8. Pt. will remain in a stable, comfortable position in bed, and avoid friction

Evaluation of Outcome: Outcome met, the pt. remained free from injury to the dermis and
epidermis for duration of care

Problem #7: Bilateral upper extremity edema r/t immobility and poor protein intake as
evidenced by left plus 2 pitting edema, and right plus 1 pitting edema

General Goal: Prevent edema from worsening, and reduce edema in the upper extremities

Predicted Behavioral Outcome Objective (s): The patient's edema will not increase and be less
than or equal to 1 in the upper extremities

Nursing Interventions:
 1. Elevate the patients arms on pillows
2. Monitor intake and output
3. Monitor weight daily
4. Monitor fluid and electrolyte status
5. Provide passive range of motion exercises in the patients upper extremities
6. Monitor vitals signs, particularly blood pressure and heart rate
7. Provide adequate nutrition to increase protein and albumin
8. Assess for presence and degree of edema in extremities and body

Patient Responses:

1. The fluid in the pt's arms will more easily flow back through the body rather than just
sitting
2. Pt's input will not be greater than output
3. Pt's weight will remain stable and not increase too rapidly
4. Pt's electrolyte levels will be in normal range
5. Circulation will improve in the upper extremities
6. Pt's blood pressure and heart rate will be in normal range
7. Pt's protein and albumin levels will be in normal range
8. Pt. will not show worsening edema or new edema

Evaluation of Outcome: Outcome not met, although pt's upper extremity edema did not
worsen, it did not improve

Problem #8: Impaired verbal communication r/t CNS impairment and recent tracheotomy
insertion as evidenced by inability to verbalize

General Goal: The patient will be able to communicate

Predicted Behavioral Outcome Objective (s): The patient will use alternate methods of
communication effectively

Nursing Interventions:

1. Establish an alternate means of communication such as coded messaging

2. Pay attention to the pt's non-verbal cues
3. Speak in front of the pt's view (pt cannot turn head)
4. Give pt. ample time to respond
5. Use yes or no questions to assess pt's needs
6. Ask one question at a time when questioning the pt.
 7. Continue to communicate with the pt. even when they cannot verbalize understanding
(the pt. may still understand everything you say and this helps fulfill the need for social
interaction)
8. Use presence and touch therapeutically

Patient Responses:

1. The pt. will be able to communicate using coded messaging

2. The pt. will be able to use non-verbal cues to communicate needs
3. The pt. will have enhanced understanding and increased social interaction
4. The pt. will have enough time to think and respond to the nurse
5. The pt. will be able to communicate simple responses
6. The pt. cannot answer multiple questions at once so answering one question at a time
will help the pt. communicate
7. The pt. will have increased social interaction and have a better understanding of
situation and care
8. The pt. will have increased social interaction and emotional support

Evaluation of Outcome: Outcome met, the pt. was able to nod to establish an alternate means
of communication