Beruflich Dokumente
Kultur Dokumente
Subjective:
-No known drug
allergies (NKDA)
-Shortness of
breath
-No hx of
smoking,
alcohol or drug
use.
-Pain
-Depressed
Objective:
Height: 410
Weight:
308lbs.
Pain: 9/10 in
LLE
4+ edema
noted
Nursing
Diagnosis with
Evidence (Nsg
Dx: related to)
Risk for
infection r/t tx
of skin infection
as evidence by
necrotizing
fasciitis.
Ineffective
breathing
pattern r/t
administration
of general
aesthetics as
evidence by
intubation.
Impaired oral
mucous
membrane r/t
NPO status and
Goal/Outco
me
(specific,
measurable
Resolution
of the s/s of
infection.
Pt will
maintain
desired
respiratory
status and
normal
ABGs.
Implementation/Intervention
s
Maintains
intact, pink
and moist
oral mucous
membranes
Rationale &
Source Citation
(w/ source,
page number)
Use of aseptic
technique
decreases
chances of
transmitting
pathogens to
the pt. Gulanick
and Myers
(2014, p.108).
Fluids promote
diluted urine
and emptying
of bladder,
reducing stasis
urine, reduces
risk for bladder
infection or UTI
(Gulanick,
2014, pg.108).
Evaluation of
Outcomes
Decreased WBC
within one
week, prior to
discharge.
Pt will breathe
easily while
intubated with
mechanical
ventilator, while
in ICU.
Absence of
inflammation of
oral mucous
membranes
while
mechanical
ventilator used.
mechanical
ventilator as
evidence by
intubation.
The presence of
pts wounds,
indwelling
catheter,
wound vac,
feeding tube
and IV sites, all
represent a
break in the
bodys normal
first line of
defense
(Gulanick,
2014, pg.107).
Signs of
respiratory
compromise
include
decreasing
PaO2 and
increasing
PaCO2
(Gulanick,
2014, pg.467).
Increases in
peak airway
pressures and
airway
resistance
parameters
signals the
accumulation of
secretions or
fluid and the
potential for
ineffective
ventilation
(Gulanick,
2014, pg.467).
Diminished lung
sounds or the
presence of
adventitious
sounds may
indicate an
obstructed
airway and the
need for
suctioning
(Gulanick,
2014, pg.467)
Mouth care
prevents
buildup of oral
plaque and
bacteria. Pts
with oxygen
therapy require
additional care
(Gulanick,
2014, pg.142).
Suctioning
prevents
accumulation of
secretion that
can be