Regan LaVigna

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Key Problem Key Problem: Key Problem:

Impaired Physical Risk for Infection Acute Pain:
Mobility: Supporting data: Supporting date:
Supporting Data: Multiple lacerations Sharp pains
Weakness Refusing dressing change Pain with movement
Tingling Dressing changes/cleanings Paresthesia
Bed rest Surgical site Wincing
AFO splint Other lacerations Crying
Tachycardic

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Key Problem
Key Problem Reason For Needing Health Care: Risk for Injury
Noncompliance: Multiple lacerations: Severed Sciatic Supporting data:
Supporting data: nerve Weakness
Refusing treatments Key assessments: Morphine as needed
Refusing PT/OT Respiratory Drowsy
Refusing wound Lung sounds Tired
assessment O2 Status Bed bound
Refusing nursing Skin assessment: wounds/lacerations
treatments

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Key Problem Key Problem Key Problem

Impaired verbal Self- care deficit: Family Anxiety:
communication: Supporting data: Supporting data:
supporting data: Not walking Ineffective decision making
Young age Severed nerve in family
Does not speak English Stress
Bed rest
Refuse to ambulate/move Poor communication
Need translator
Not compliant Language barrier
Doesn’t leave bedside
 Problem # ___1____: Impaired Physical Mobility
General Goal: Patient will work with PT

Predicted Behavioral Outcome Objective (s): The patient will…… Move from the bed to the
chair with PT
on the day of care.

Nursing Interventions Patient Responses

1. Help with transfer methods 1. In pain and cried but able to move to chair
2. Apply AFO splint after PT 2. Prevents hip from moving
3. Give positive reinforcement during activity 3. This is to boost patients chances of recovering and
Increasing self esteem.
4. Turn and reposition Q2 hours 4. Position changes optimizes circulation to all tissues and relive
Pressure

Evaluation of outcomes objectives: Patient transferred over from the bed to a chair with PT, assisted x3.

Problem # ________2_________: Risk for Infection

General Goal: allow nurse to change dressing

Predicted Behavioral Outcome Objective (s): The patient will…… remain infection free by
having vital signs within normal range
on the day of care.

Nursing Interventions Patient Responses

1. Teach importance of cleaning wound 1. Proper wound management=wound irrigation as it leads

to better wound healing, decreased risk of infection, and decreased

risk of hospital re-admission

2. Hand washing before and after 2. best ways to avoid getting sick and prevent spread germs to others
3. Vital Signs q 4 3. Fever is sign of infection
4. Continuous Pulse Ox 4. Easy way to tell how well oxygen is being sent to body parts

Evaluation of outcomes objectives: Did not meet the original goal of allowing the nurse to change the
dressings but remained free from any signs of infection.
 Problem # ___3____: Acute Pain
General Goal:

Predicted Behavioral Outcome Objective (s): The patient will…… State that his pain is
managed through his pain medications

on the day of care.

Nursing Interventions Patient Responses

1. Provide measures to relieve pain
2. Using distraction techniques
3. Provide scheduled Opioids
4. Provide Non-Opioids
1.. Pain meds useful before wound dressing changes/physical therapy
Or non-pharmacologic relief
2. play with client or turning on TV helps take mind off pain
3. For extreme pain
4. For mild pain relief

Evaluation of outcomes objectives: Patient was able to sleep a lot today due to pain being manageable and
from missing out on sleep from the night before

Problem # ______4___________: Noncompliance

General Goal: Educate family on patients care

Predicted Behavioral Outcome Objective (s): The patient will…… Allow PT to come in and
work with movement and transferring
on the day of care.

Nursing Interventions Patient Responses

1. Develop therapeutic relationship with 1. Allows patient gain trust from the nurse.
Patient and family
2. Educate patient and family of the importance 2. Increases compliance to treatments and awareness
Of the treatment regimen that patient will undergo
3. Create system of rewards following 3.Rewards provides positive reinforcement
completion of treatments for compliant behavior
4. Involve the patient in their treatment 4. Patients who are included in their planning, have a greater steak in
 Achieving a positive outcome

Evaluation of outcomes objectives: Patient was compliant today with nurses and allowed PT to come in
and work with him. The nurses and staff did a great job communicating exactly what was going on and
theProblem
steps they were taking
# ____5___: Riskduring the plan of care.
for Injury
General Goal: Refrain from falls

Predicted Behavioral Outcome Objective (s): The patient will…… Remain free from injuries
and verbalize factors that influence their risk of injuries
on the day of care.

Nursing Interventions Patient Responses

1. Ask family to be with the patient to prevent 1. To prevent the patient from accidental injury, falling.
accidental falls/injuries
2. Validate the patient’s feelings and concerns 2. Validation lets patient know they are heard and understood
Related to environmental
3. In bed activities 3. Reduces physical activity and risk for injuries
4. Educate patients on safe ambulation at home 4. Home safety should be assessed, discussed with clients and

caregivers
Evaluation of outcomes objectives: The staff/ nurses made sure the child was safe at all times. Family was
in the patients room at all times ensuring the child was safe. All safety measures were taken when
performing actions such as transferring and moving.

Problem # _______6__________: Impaired verbal communication:

General Goal: Cooperate effectively with patient and family

Predicted Behavioral Outcome Objective (s): The patient will…… Understand what the plan for
the day is and what treatments we are doing
on the day of care.

Nursing Interventions Patient Responses

1. Clarify understanding with an interpreter 1. Promotes effective communication

2. Give patient and family time to respond 2. May be difficult to respond under pressurend may need time to
organize thoughts
3. Phrase questions with “yes” or “no” responses 3. Can get frustrated when they cannot answer in simple manor
4. Speak slowly 4.provides patient with more channels through which information
Can be communicated

Evaluation of outcomes objectives: We were able to communicate effectively through the use of the
translator.
 Problem # ____7___: Self care deficit
General Goal: monitor self care abilities

Predicted Behavioral Outcome Objective (s): The patient will……

Assist with ADLs throughout the day
on the day of care.

Nursing Interventions Patient Responses

1. Assess physical tolerance and abilities to perform ADL 1. Provides information about the amount of energy

And effect of illness on activity level

2. Praise child for participating in own care 2. Promotes self esteem and independence
3. encourage rest and quiet periods 3. Ensures proper rest and prevents fatigue
4. Encourage parents to assist in childs ADLs 4. Promotes some control by the child w/out separating from parent
But allow the child independence as much as possible

Evaluation of outcomes objectives: The mother of the child helps out the patient a lot and sometimes
takes over for the patient too much. However, this decreased throughout the day.

Problem # ________8_________: Family Anxiety

General Goal: Assist in anxiety reducing skills

Predicted Behavioral Outcome Objective (s): The patient will…… Communicate with nurses
when they have concerns or questions
on the day of care.

Nursing Interventions Patient Responses

1. Recognize awareness of anxiety 1. Validates the feelings and communicates acceptance of those
Feeling
2. Interact with them in a calm manor 2. The nurse can transmit their own anxiety onto the patient and their
family
3. Converse using simple and concise statements 3. Family is already anxious about the language barrier so try
and
And keep language simple
4. Allow patient and family to express feelings 4. Talking about feelings can help with recognizing the factors

Evaluation of outcomes objectives: Eventually, the family started to let the nurses and doctors do their
jobs and allowed them to assist their child and take care of him.