Desired Outcomes

1. Pain
Patient reports satisfactory pain
level of 0 out of 10 by the end of
the clinical shift.

2. Impaired physical mobility

Patient will remain free of
complications of immobility by
maintaining intact skin, clear breath
sounds, and absence of
thrombophlebitis by the end of the
clinical shift.

3. Infection
Patient will not show worsening
S/S of infection by the end of the
clinical shift.

4. Decreased oxygenation
Patient will maintain effective
breathing pattern by clear lung
sounds, normal RR, and absence of
dyspnea by the end of clinical shift.

Interventions
1. Assess pain (PQRST)
2. Administer pain medications as
needed
3. Respond immediately to
complaint of pain
4. Initiate non pharmacological pain
methods
5. Observe or monitor S/S
associated with pain, such as BP,
HR, temperature, color, and
moisture of skin, restlessness, and
ability to focus
6. Teach the patient effective timing
of the medication dose in relation to
potentially uncomfortable activities
and prevention of peak pain periods
1. Assess and compare
neurovascular status of all
extremities for developing
thrombophlebitis
2. Apply antiemoblic hose or
sequential compression devices as
indicated to prevent
thrombophlebitis
3. Assist with early ambulation
4. Provide a safe environment: bed
rails up, bed in down position,
necessary items close by
5. Teach the patient active or
passive ROM while in bed
6. Reposition patient Q2H as
needed. Maintain limbs in functional
alignment (with pillows, sandbags,
splints, or prefabricated splints.
1. Assess for presence, existence of,
and history of risk factors such as
open wounds, abrasions, venous or
arterial access devices, etc.
2. Monitor WBC count
3. Monitor for S/S of infection:
redness, swelling, increased pain,
elevated temperature, purulent
drainage from incision, injury, and
exit site of tubes, drains, or catheters
4. Assess immunization status
5. Maintain or teach asepsis for
dressing changes and wound care
6. Teach patient or caregivers to
wash hands before contact or
between procedures with the patient
1. Assess respiratory rate, rhythm,
and rate
2. Monitor for changes in LOC
3. Assess for complications
4. Position the patient with proper

Evaluation
This outcome was measured
by assessing the patients
pain and then administering
pain medication. Patient was
not able to rate her pain, but
after pain medication was
given, effectiveness was
checked one hour later and
patient stated that she did not
have any more pain. This
outcome was met.

This outcome was met. This

outcome was measured by
assessing the patients skin
from head to toe, lung
sounds were clear bilaterally,
and patient didnt exhibit
any S/S of thrombophlebitis
such as redness, warmth,
pain, swelling, +Homans,
increase in temperature.
Patient was repositioned
Q2H and SCDs applied
while in bed.

This outcome was measured

by monitoring patients daily
lab values of WBC and
neutrophils. Her vitals were
monitored and she didnt
show signs of increase
temperature, BP, HR. Her
surgical site was clean, dry,
and intact. Outcome was
met. Flu shot was given prior
to discharge.

This outcome was measured

by assessing patients
respiratory status. Patient
exhibited clear lungs sounds,
normal RR, and didnt show

body alignment for optimal

breathing pattern
5. Maintain O2 sat >95%
6. Teach the patient how to use
incentive spirometer

5. Impaired Skin integrity

Patients skin will remain intact and
show no redness over bony
prominences by the end of clinical
shift.

6. Deficient Knowledge
Patient verbalizes understanding
and/or demonstrates post op care by
discharge.

7. Fatigue/Weakness
Patient will help participate in
performing ADLs with the SN
during the clinical shift.

1. Reposition Q2H
2. Assess general condition of skin,
but especially over bony
prominences
3. Teach the patient causes of
pressure ulcer development:
incontinence, pressure especially on
bony prominences, poor nutrition,
shearing or friction
4. Keep skin clean and dry from
moisture such as urine, sweat,
drainage, body fluids
5. Use pressure relieving devices to
keep bony prominences from direct
contact with each other
6. Reinforce the importance of
mobility, turning, ambulation in
prevention of pressure ulcers
1. Assess the patients
understanding of treatment.
2. Assess the patients
understanding of follow up care.
3. Determine the patients
recognition of hazards in the home
that will compromise the patients
ability to be effectively mobile at
home.
4. Instruct the patient in surgical site
care.
5. Teach the patient to observe for
signs of infection and notify the
physician is they develop.
6. Provide the patient with medical
supplies and assistive devices as
needed.
1. Assess the patients description of
fatigue: timing (continuous or at the
end of the day), aggravating, and
alleviating factors
2. Encourage patient to maintain
nutritional intake for adequate
caloric requirements
3. Encourage good sleep hygiene to
maximize rest
4. Assess the patients emotional

any difficulty in breathing

such as nasal flaring,
retractions, shortness of
breath, or use accessory
muscles. Vital signs were
stable, O2 sat remained
above 95%. Incentive
spirometer was educated
during the clinical shift and
completed. Outcome was
met.
This outcome was met. This
was measured by assessing
patients skin from head to
toe, repositioning the patient
Q2H, used pillows to
prevent bony prominences
from direct contact. Briefs
were checked consistently
and changed promptly or
changed when told it was
wet by the patient.

This outcome was partially

met. This outcome was
measured by the patient
verbalizing understanding of
treatment plan, follow up
care, and surgical site care.
Patient verbalized
understanding of
complications or S/S to
notify the physician. Patient
was not able to demonstrate
any interventions.

This outcome was partially

met. This outcome was
measured by patients
participation with ADLs.
Although patient did help
assist, patient needed 2-man
assist with activities because
she was not able to move
well independently.

8. Elimination
Patient will maintain output of 30
mL/hr during the clinical shift.

response to fatigue
5. Determine the patients nighttime
sleep pattern
6. Assist patient with daily ADLs in
cluster format to balance rest in
between
1. I/O
2. Assess for S/S of UTI: frequency,
burning, elevated temperature,
elevated WBC
3. Encourage oral fluids
4. Assess abdomen for bladder
distention
5. Assess frequency, amount, and
character of urine and for any S/S of
incontinence
6. Notify the physician of any
abnormalities in the urine or the
process of voiding

This outcome was partially

met. Patient used the
bathroom many times during
the clinical shift, but urine
output was not measured.
Urine culture was positive
for UTI and WBCs were
elevated. Patient denied any
S/S of UTI, urine was clear
with no odor. Abdomen was
soft and non-distended.
Patient consistent with fluid
intake.

Discharge Plan/Patient Teaching

Patient will be discharged to a rehabilitation facility where she will learn proper techniques from
PT and OT to help transition to her home where she lives alone. Patient is widowed, but has family support
from her son. Patient was living alone previously with no help from her son because she was independent.
Patient will need help with cleaning, cooking, showering, toileting. In the beginning she may need total
assistance until she gets stronger and is able to do more on her own. At this time, there is no plan for who
will be helping her. Patient will need a walker to ambulate within the house, a wheelchair for long
distances, and wound care supplies to maintain proper wound care to surgical site.
Patient states she learns best with written instructions rather than verbal instructions. Her barriers
to learning include dementia and she is not able to see out of her left eye. Patient will need to maintain
follow up appointments with her MD to check on her surgical wound. Patient will need to choose a healthy
diet rich in protein to help with wound healing and make her strong to be close to being independent again.
Patient had an active infection according to her labs, so she will need to comply with antibiotics and
continue to take them out of the hospital. Patient will need to ambulate with an assistive device at all times
because of her unsteadiness and to prevent future falls or injuries. Patient will need to learn proper
techniques from PT to maintain proper alignment of the hip and prevent further damage to the area. Patient
should exercise slowly and as tolerated to gain muscle and become stronger. Patient will need to monitor
surgical site for complications such as bleeding or infection. She should also watch for complications of
DVT or pneumonia. Patient will need to monitor for S/S of infection such as increased BP, HR,
temperature, redness, warmth, swelling, drainage to incision site. Monitor for S/S of bleeding such as red
tinge body fluids, decreased BP, increased HR, clammy skin, weakness, bruising, dizziness. Monitor for
S/S of DVT such as increased calf pain, increased temperature, swelling, warmth, tenderness to calf area.
Monitor for S?S of pneumonia such as increased respiratory rate, temperature, HR, cough, sputum, fatigue,
sweating, chills, shortness of breath, loss of appetite. If you notice any of these symptoms, you need to seek
medical treatment immediately. If you feel different than normal all of a sudden, call your MD.