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Problem # ____1___: Impaired Gas exchange

General Goal: Increased gas exchange

Predicted Behavioral Outcome Objective (s): The patient willremain free of acute respiratory distress
episodes while maintaining SPO2 > 92% .On the day of care

on the day of care.

Nursing Interventions Patient Responses

1. NC 2L O2 1. Desaturation below 80%

2. Face mask 12L O2 2. SPO2 91%
3. Raised HOB to 45 degrees 3. SPO2 95% (with 12L FM)
4. Paused 0.45 NS 4. Pt. reported less frequent
coughing, SPO2 >95%
5. Reduced pts activity (bed rest) 5. S&S of comfort, decreased RR
6. Asses Chest XR 6. No significant findings
7. Auscultate breath sounds, effort 7. Diminished lung sounds
bilaterally, crackles & ronchi
present all lobes L&R

Evaluation of outcome objectives: Not met- pt. had difficulty maintaining SPO2 within normal range. Pt.
experienced multiple episodes of respiratory distress including a RR of 40, SPO2 at 80%, and HR of 135+.
Patients respiratory status returned to desired level with nursing intervention.

P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis, 2002.

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Problem # ___2____: Fluid Volume Defecit

General Goal: Balanced Fluid Volume

Predicted Behavioral Outcome Objective (s): The patient will Have balanced I&Os, see changes in
serum lab values indicative of adequate hydration and maintain 30 mL of urine outputOn day of care

on the day of care.

Nursing Interventions Patient Responses

1. Monitor VS (HR & BP specifically) 1. 128/69, 129HR, 37RR

2. Assess skin turgor and mucous membrane 2. Skin turgor >3second, membranes dry
and cracked
3. Assess for altered mental status 3. Pt. remained A&O X4 through shift
4. Assess color and amount of urine 4. Urine amber, approximately 80mL/hr
5. Administer maintenance IV fluids 5. Labs progressing toward normal limits
since admission
6. Monitor and document temperature 6. 97 (febrile state decreases fluids)
7. Note presence of nausea and vomiting 7. Pt. experiencing N&V since
admission. Approx 250 mL on shift
8. Monitor for active fluid loss 8. Active GI bleed- no current S&S
Evaluation of outcome objectives: Partially met: Pt.s Is&Os trending toward even balance since admission.
Problem # ___3____:
Maintained Risk output
30 mL urinary for Aspiration
per hour during shift. No active signs of bleeding noted (hematemesis,
General Goal: Avoid aspiration andA&O
tachycardia with low BP, melena). remove/reduce causative
X4. Pt. afebrile so nofactors of of
addition riskinsensible fluid loss in that regard.

Predicted Behavioral Outcome Objective (s): The patient will remain free of aspiration and reduce risk
for aspirationon the day of care.

Nursing Interventions Patient Responses

1. Assess LOC 1. A&O X4

2. Monitor RR, depth, effort 2. 36, shallow, high effort. Cough
3. Assess for presence of N&V 3. Both present, ~250mL on shift
4. Auscultate bowel sounds 4. Hypoactive X4
5. Assess pulmonary status including 5. Crackles and ronchi present, chest
breath sounds, specifically crackles XR not indicative of infiltrates
and rhonchi/ Chest XR
6. Keep HOB elevated 6. Decrease in emesis volume
7. Administer antiemetic meds 7. Persistent N&V through shift

Evaluation of outcome objectives: Partially met- Although the patient remained free of aspiration during the
shift I did not feel the risk was reduced. The pts respiratory status was compromised on multiple occasions
and N&V was persistent through shift.
P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis, 2002.
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P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis, 2002.

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Problem # ___4____: Unstable blood glucose

General Goal: Reduce glucose fluctuations and return levels to normal range

Predicted Behavioral Outcome Objective (s): The patient willHave a blood glucose level of less than
180mg/dL and be free of S&S of hyperglycemia.On day of care

on the day of care.

Nursing Interventions Patient Responses

1. Assess for signs of hyperglycemia 1. Reports fatigue. Blood glucose 390

2. Assess for anxiety,tremors,slurred speech
3. Assess pattern of physical activity
4. Administer basil insulin
5. Educate patient on monitoring BG levels
6. Report systolic BP of >160
7. Monitor Serum createnine/BUN
2. None present (hypoglycemic S&S)
3. Pt. on bed rest
4. IV drip insulin 1:1 ratio @ 16mL/hr
5. Pt. responded he knew when/how to
check his sugar and then swore at me
6. Pts systolic BP remained <160
7. Createnine 3.1; BUN 82

Evaluation of outcome objectives: NOT MET- Pts lowest glucose reading during shift was 390 and insulin
was raised from 12 to 16 units/hour. Patient continues to exhibit severe dehydration symptoms r/t DKA. Also
exhibiting S&S of renal injury/insufficiency

Problem # ___5____: Decreased Cardiac Output

General Goal: Increase Cardiac Output

Predicted Behavioral Outcome Objective (s): The patient willhave adequate cardiac output during shift
as evidence by pulse 60-100, systolic > 100, ANO X3, palpable pulses On day of care

on the day of care.

Nursing Interventions Patient Responses

1. Assess VS 1. 128/69, 129HR, 37RR, 97% (9AM)

2. Assess skin color/temp 2. Warm to touch; appropriate for ethnicity
3. Monitor MAP 3. 88 MAP
4. Monitor urinary output 4. 78mL/hr during shift
5. Assess for edema 5. No edema present
6. Check peripheral pulses & cap 6. Peripheral pulses present, cap
refill refill <3
7. Monitor LOC and orientation 7. A&O X4 through shift
8. Monitor ECG 8. Sinus tachycardia

P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis, 2002.

Evaluation of outcome objectives: MET- Pt. experienced tachycardia throughout the day, however it was not
accompanied by hypotension or a low MAP. All other assessment data assessing C.O. was WNL.

Problem # ___6____: Risk for Impaired Skin Integrity

General Goal: Pt. will remain free impairment on skin integrity

Predicted Behavioral Outcome Objective (s): The patient willremain free of sores or lesions on DOC and
remain compliant with policies regarding Braden Scaleon day of care

on the day of care.

Nursing Interventions Patient Responses

1. Educate pt. on importance of clean/dry 1.Pt. verbalized understanding

skin
2. Reposition pt. q2H 2. Skin shows no signs of advancing
impairment
3. Monitor skin q24 for changes 3. No documented changes in assessment
from previous days assessment
4. Educate the pt. on effect of diabetes on 4. Verbalized understanding and repeated
wound development
5. Preform Braden Scale Assessment 5. Scored a 17 on Braden scale
6. Use ordered pressure reducing mattress 6. Reported increased comfort

Evaluation of outcome objectives: MET- Pt.s skin showed no signs of advancing skin impairment. Remained
compliant with turn schedule and calling for a nurse to use the bathroom. Pt. was also compliant in education
and verbalization of understanding.
Problem # ___7____: Inefficient management of therapeutic regimen
General Goal: Effective management of therapeutic regimen

Predicted Behavioral Outcome Objective (s): The patient willVerbalize understanding of the implications
of not following the therapeutic regimen strictly.On day of care

on the day of care.

Nursing Interventions Patient Responses

1. Assess for signs of noncompliance
2. Assess contributing factors leading to
Ineffective management
3. Educate pt. on risks of further damage
4. Review appropriate times to check BG
1. Pts wife informed staff of pts long
term lack of compliance
2. Pt. identifies complacency, apathy, and
feelings of hoplessness as factors
3. Pt. verbalazied understanding of
increased risk for CVA, HTN, pressure
sores, infection, and ultimate shortened
lifespan
4. Pt. responded before meals and bed
5. Review the risks of skipping insulin dose 5. Pt. discussed episodes resulting in
hospitalization due to extremely high
sugar- also stated he would like to avoid
these visits in future

Evaluation of outcome objectives: NOT met- Although pt. verbalized understanding to the SN it was noted
by the patient he was only compliant to get me out of the room. Pt. carries large self care deficit. Further
intervention may be suggested to prevent further complication. Discussed possible psych consult as well as
diabetic teaching with cover nurse