NURSING MANAGEMENT Actual Nursing Care (SOAPIE)

June 20, 2010 2-10 shift

PROBLEMS: #1 #2 #3 INEFFECTIVE AIRWAY CLEARANCE R/T RETAINED SECRETIONS HYPERTHERMIA INEFFECTIVE TISSUE PERFUSION R/T DECREASED HEMOGLOBIN

CONCENTRATION IN THE BLOOD

S> O> Received patient on bed, conscious and coherent with IVF of #1 PNSS 1liter x 40 cc/ hr, SD1 BT 1 unit PRBC serial number (1011855) 250 cc infusing well on left cephalic vein, with O2 via nasal cannula at 2 lpm, with foley catheter, with initial vital signs as follows: T-37.9OC / axilla, P-13 bpm, R26 breaths/min, BP90/50 mmHg, O2 saturation- 92% A>Ineffective Airway Clearance r/t retained secretions Hyperthermia Ineffective Tissue Perfusion r/t Decreased Hemoglobin Concentration in the Blood P> After 4 hours of nursing intervention, the patient will expectorate secretions After 4 hours of nursing intervention, patients temperature will decrease to 37.5 OC After 4 hours of nursing intervention, patients capillary refill will be less than 3 seconds I> Assessed patient

>Monitored and recorded vital signs and I&O every 1 hour >Monitored vital signs every 15 minutes during transfusion up to 30 minutes post blood transfusion >Assessed patient for any transfusion reaction >Checked IV site and IV fluid >Regulated IV fluid as ordered >Checked O2 inhalation >TSB done >Paracetamol 300mg/tab given >Started duavent neb every 6 hours c/o RT >BP of 80/50 @ 3:06 pm, fast drip of 150 cc done >Provided comfort and safety measures >Encouraged patient to deep breath >Due medications given >Due needs attended E> Goal met as evidenced by patient can expectorate secretions, temperature is decrease from 37.9OC to 37.5OC and patients capillary refill is 2 seconds

June 21, 2010 10-6 shift

PROBLEM: INEFFECTIVE AIRWAY CLEARANCE R/T RETAINED SECRETIONS S> O> Received patient on bed, with GCS 0f 13-14 points (E3-4, V4, M6), with venturi mask at 40% FiO2, with IVF of #5 PNSS 1 liter + 40 meqs KCl x 100 cc/hr, with SD levophed drip (4mg in 96 cc D5W) x 2mcg/kg/min infusing well on left cephalic vein, with IVF of PNSS 500 cc x 10 cc/hr on right metacarpal vein ,with foley catheter, with initial vital signs as follows: T 38.1OC / axilla, P130 bpm, R29 breaths/min, BP120/70 mmHg, O2 saturation- 87-91% A> Ineffective Airway Clearance r/t retained secretions P> After 4 hours of nursing intervention, patient will have a patent airway and will be able to expectorate secretions I> Assessed patient >Monitored and recorded vital signs and I&O every 1 hour >Checked IV site and IV fluid >Regulated IV fluids as ordered >TSB done > duavent neb done c/o RT >CPT done after every nebulization >Turning of patient every two hours and as tolerated > Encouraged patient to deep breath >Glucose monitoring done >Provided comfort and safety measures >Due medications given >Due needs attended E> Goal partially met as evidenced by patient have a patent airway but not able to expectorate secretions R> Reinforce the previous interventions

June 22, 2010 2-10 shift

PROBLEM: INEFFECTIVE AIRWAY CLEARANCE R/T RETAINED SECRETIONS S> O> Received patient on bed, with GCS 0f 9-11 points (E3-4,VET 1,M6), with ET to mechanical ventilator with the following settings: TV= 500, FiO2=50%, BUR=20, AC mode, with an IVF of # 7 PNSS 1 liter + 20 meqs KCl x 100 cc/hr infusing well on left cephalic vein, with IVF of #2 PNSS 500ccx 10 cc/hr, with side drip of #1 KCl drip via soluset (40 meqs KCL in 80cc PNSS) x 8 hours infusing well on right cephalic vein , with oral airway, with NGT inserted on left nares, with foley catheter, with initial vital signs as follows: T 39.1OC / axilla, P 130 bpm, R 29 breaths/min, BP 110/60 mmHg, O2 saturation- 87- 93% A>Ineffective Airway Clearance r/t retained secretions P> After 4 hours of nursing intervention, patient will have a patent airway I> Assessed patient >Monitored and recorded vital signs and I&O every 1 hour > Nebulization done c/o RT >CPT done after every nebulization >Turning of patient every two hours and as tolerated > Encouraged patient to deep breath >Mechanical ventilator settings checked >Suctioned oral and ET secretions >Flushing of NSS done >Oral care done >Due needs attended E> Goal met as evidenced by patient have a patent airway

June 23, 2010 6-2 shift

PROBLEM: HYPERTHERMIA S> O> Received patient on bed, with GCS 0f 9-11 points (E3-4,VET 1,M6), with ET to mechanical ventilator with the following settings: TV= 500, FiO2=50%, BUR=20, AC mode, IVF of # 9 PNSS 1 liter + 20 meqs KCl x 100 cc/hr infusing well on left cephalic vein, with IVF of #4 PNSS 500ccx 10 cc/hr, with side drip of#2 KCl drip via soluset (40 meqs KCL in 80cc PNSS) x 8 hours infusing well on right cephalic vein, with oral airway, with NGT inserted on left nares, with foley catheter, with initial vital signs as follows: T 38.1OC / axilla, P -136 bpm, R 32 breaths/min,BP 110/60 mmHg, O2 saturation- 88- 92%

A>Hyperthermia P> After 4 hours of nursing intervention, patients temperature will decrease to 37.5
O

I> Assessed patient >Monitored and recorded vital signs and I&O every 1 hour >Checked IV site and IV fluid >Regulated IV fluids as ordered >TSB done > Nebulization done c/o RT >CPT done after every nebulization >Turning of patient every two hours and as tolerated > Encouraged patient to deep breath >Mechanical ventilator settings checked >Suctioned oral and ET secretions >Flushing of NSS done >Oral care done >Glucose monitoring done >Checked NGT patency

>OF given >Provided comfort and safety measures >Due medications given >Due needs attended E> Goal not met as evidenced by patients temperature is only 37.9C R> Reinforced previous intervention