Assessment Nursing Diagnosis Goals & Expected Outcomes Nursing Interventions Evaluation

(Supporting data) (NANDA diagnostic statement) (Realistic, timed, measurable) (Strategies or actions for care) (Client’s response to nursing actions
Rationale for interventions & progress toward achieving
goals & outcomes)
Subjective: Impaired Gas Pt will not • Continuous pulse ox
“I can’t breathe” Exchange R/T develop Assessment of pt’s Pt did not develop
inability to pulmonary baseline O2 sats is pulmonary
transport oxygen complications necessary to titrate O2 complications during
AEB hypoxemia during hospital hospital stay
• Baseline ABGs
and cyanosis stay Respirations will
• Titrate O2 to keep sats
remain 12-20 BPM
Pt’s O2 sat will > 95%
remain >95% Ensures adequate
Objective: during hospital perfusion to tissues Respirations
Restless, ↓ O2 stay • Teach pt IS use every 2 remained 12-20 BPM
sats Respirations will hours while awake
remain 12-20 Helps prevent
BPM atelectasis
ABGs will be NML • Encourage cough,
at least 24 hours repositioning, and
before D/C (PaO2 deep breathing Q 2
80-100; PaCO2 hours
35-45; pH 7.35- Helps prevent
7.45) atelectasis
• Instruct pt not to cross
legs or wear tight
stockings
Impairs venous return;
increases risk of PE
Subjective: Acute Pain R/T Within 1 hour of • Pre medicate before
“My pain is 9/10” tissue ischemia intervention, pt’s activities Pt reported pain relief
AEB guarding, subjective pain Provides comfort of 2/10 after
moaning, verbal level will during activity administration of
rating of pain decrease. • Encourage pt to morphine
9/10 Objective request pain meds
indicators of pain before pain becomes
(grimacing, severe or administer at
Objective: moaning) will scheduled intervals
moaning, diminish. Prolonged stimulation
guarding of pain receptors
Pt will maintain results in increased
adequate pain sensitivity to pain,
control during increasing the amt of
hospital stay drug needed to relieve
pain
• Help pt with non-
pharm pain
management
(relaxation, distraction,
positioning, etc.)
• Teach pt to splint chest
when coughing,
moving
Reduces discomfort
and increases
compliance with TCDB
 Assessment Nursing Diagnosis Goals & Expected Outcomes Nursing Interventions Evaluation
(Supporting data) (NANDA diagnostic statement) (Realistic, timed, measurable) (Strategies or actions for care) (Client’s response to nursing actions
& progress toward achieving goals
& outcomes)
Subjective:

Risk of Fluid Pt remains • Monitor I&O

Pt did not hemorrhage
Volume Deficit normovolemic • Weigh patient
during hospital stage
R/T acute blood throughout daily
loss hospital stay • Monitor lab
Objective: Pt shows no values to eval
signs of external lytes, h&h and
or internal fluid balance
hemorrhage These
Pts VS remain assessments all
stable (BP WNL, eval fluid , lyte
RR 12-20, HR 60- and hemo
80) status
• Monitor stool
for occult blood
• Monitor for
sudden thirst
Indicative of
hemorrhage
• Inform pt to use
 electric razors,
soft
toothbrushes,
etc. to avoid
bleeding
• Institute fall
precautions