1.

Impaired swallowing
AMS
Dysphagia
Soft-textured regular diet
Thickened fluids (nectar)
Assess for coughing/chocking during mealtimes
Assess for residual food in mouth after eating
Oral care
Reduce environmental stimuli
High-fowlers during meals
Encourage to chew slowly & thoroughly

4. Impaired tissue integrity
Bilateral Burr hole drainage on
9/29/15 steri-strips on cerebral
incisions
Exploratory Laparotomy, open
cholecystectomy on 10/9/15
abdominal incision/dressing
Redness in groin area bilaterally
Nystatin

Chief Medical Diagnoses:

Bilateral subdural
hematomas s/p bilateral
Burr Hole drainage &
gangrenous cholecystitis
s/p open cholecystectomy

Priority Assessments:
Swallowing ability, LOC,
pain, skin-cerebral
incisions, abdominal
incision, mobility
allowance, learning
ability/willingness to learn

3. Impaired physical mobility

Bilateral Burr hole drainage on 9/29/15
Exploratory Laparotomy, open cholecystectomy
on 10/9/15
=Post-op status
Hx of incoordination
Active alcoholism
PT & OT treatments

6. Ineffective Health Maintenance

AMS
Alcoholism
Continues to consume alcohol daily despite
liver cancer hx
Did not report un-witnessed fall to family
Hx of refusal to go to ER for change in mental &
speech status, & dominant hand weakness

2. Acute Pain
Bilateral Burr hole drainage on 9/29/15
Exploratory Laparotomy, open cholecystectomy on
10/9/15
Pain assessments
Offer pain medication
Evaluate effectiveness of pain medication
Tylenol

5. Deficient knowledge
AMS
Dementia
Disorientation, unspecified
Did not report un-witnessed fall to family
Hx of refusal to go to ER for change in
mental & speech status, & dominant hand
weakness
Hx of restraint needs

Desired outcomes
Interventions
Impaired swallowing
Impaired swallowing
1.Patient exhibits ability to safely
1. Assess for coughing or choking
swallow, as evidenced by absence of
during eating and drinking.
aspiration, no evidence of coughing or
2. Assess the ability to swallow a
choking during eating/drinking, no
small amount of water
stasis of food in oral cavity after eating,
3. Assess for residual food in the
and inability to ingest foods/fluid during
mouth after eating
the clinical shift.
4. Remove or reduce any

environmental stimuli

5. Maintain the patient in high
fowlers position with head flexed

slightly during meals.

6. Encourage the patient to chew
thoroughly, eat slowly, and
swallow frequently.

Acute pain
Acute pain
1. Patient will report satisfactory pain
1. Assess pain characteristics
control at a level less than 3 to 4 on a
2. Respond immediately to reports
rating scale of 0 to 10 by the end of the
of pain
clinical shift.
3. Provide rest periods to facilitate

comfort, sleep, and relaxation
4. Anticipate the need for pain relief
5. Give analgesics as ordered
6. Evaluate effectiveness of pain
medication

Impaired physical immobility
Impaired physical immobility
1. Patient is free of complications of
1. Assess the ability to perform ROM
immobility, as evidenced by intact skin,
to all joints
absence of thrombophlebitis, normal
2. Assess skin integrity for signs of
bowel pattern, and clear breath sounds
redness and tissue ischemia
during clinical shift and hospitalization.
especially over bony prominences

3. Provide a safe environment: bed

rails up, bed in down position,

necessary items close by.

4. Perform passive or active ROM

exercised to all extremities.

5. Encourage the appropriate use of

assistive devices
6. Ensure intermittent SCD is in
place and on when patient is in
bed and teach patient of its
purpose

Impaired tissue integrity

1. Patients tissues will return to normal
structure and function after two months
of being discharged.







Deficient knowledge
1. Patient verbalizes understanding of
and demonstrates ability to perform
postoperative care after discharge

Impaired tissue integrity

1. Assess the condition of the tissue
2. Assess the characteristics of the
wound, including color, size
(length width, depth), drainage,
and odor
3. Assess for elevated body
temperature
4. Identify for signs of scratching
and itching
5. Maintain sterile dressing
technique during wound care
6. Administer antibiotics as ordered
Deficient knowledge
1. Determine who will be the
learner: the patient, family,
significant other, or caregiver.
2. Identify the priority of learning
needs within the overall care
plan.
3. Give clear, thorough explanations
and demonstrations.
4. Teach the patient to perform
appropriate wound care:
Abdominal incisions
Dressings
5. Teach the patient the
appropriate activities: no lifting
more than 10 pounds for 6 weeks,
return to work in 3 or 4 days (not
needed), showering and bathing
are acceptable.
6. Instruct the patient to seek
medical attention for any of the
following: temperature higher
than 38 C (100.4 F), foul-smelling
wound drainage, redness or
unusual pain in any incision, or
the absence of bowel movements.

Ineffective health maintenance

1. Pt. demonstrates positive health
maintenance behaviors as evidenced by
keeping scheduled appointments,
participating in smoking or substance
abuse programs, making diet and
exercise changes, improving home
environment, and following treatment
regimen.

Ineffective health maintenance

1. Assess the patients knowledge of
health maintenance behaviors
2. Determine the patients motives
for failing to report symptoms
reflecting change in health status.
3. Assess the hx of other adverse
personal habits, including
smoking, obesity, lack of exercise,
and alcohol or substance abuse
4. Assess hearing and orientation to
time, place, and person to
determine the patients
perceptual abilities.
5. Involve family and friends in
health-planning conferences
6. Provide the patient with a
rationale for the importance of
behaviors such as the following:
Proper nutrition
Cessation of alcohol and
drug abuse
Regular physical and
dental checkups and
screenings
Reporting of unusual
symptoms to a health
professional

Evaluation

1. The desired outcome of patient exhibits ability to safely swallow, as
evidenced by absence of aspiration, no evidence of coughing or choking
during eating/drinking, no stasis of food in oral cavity after eating, and
inability to ingest foods/fluid during the clinical shift will be measured by
observing and monitoring patient during mealtimes. This outcome was met
because I assessed for coughing and choking during mealtimes, and there
wasnt any; I assessed for the ability to swallow a small amount of thickened
fluid before the patient initiating eating, which he was able to do; I observed
for bulging in the patients cheeks after meals and asked him to open his
mouth to ensure there was no residual food leftover; I ensured the patient
was not too distracted during mealtimes; I maintained his position in highfowlers during mealtimes, and I also encouraged the patient to take his time
eating and chewing his food.

2. The desired outcome of patient will report satisfactory pain control at a
level less than 3 to 4 on a rating scale of 0 to 10 by the end of the clinical
shift will be measured by assessing pain after pain medication
administration. This outcome was met because I anticipated the need for
pain relief, and after the nurse and I did pain assessments, the nurse
responded immediately by administering pain medication. Then, in about an
hour, the effectiveness of the pain medication was evaluated, and the patient
stated that he did not have any pain before we got him ready for discharge. I
also allowed for periods of rest during the clinical day when possible.
3. The desired outcome of patient is free of complications of immobility, as
evidenced by intact skin, absence of thrombophlebitis, normal bowel
pattern, and clear breath sounds during clinical shift and hospitalization can
only be partially met because I can only account for the time I was assigned
to him even though I think I would have been made aware of any of these
complications during this hospitalization. The outcome was met during the
time I was assigned to this patient though because I assessed the ability to
perform ROM on all joints and encouraged active ROM exercises; I assessed
the patients skin and was intact besides under CDI surgical abdominal
dressing and free of redness; I provided a safe environment; I encourages
the use of his walker each time he got out of bed, and I ensured the
intermittent SCDs were on while in bed and explained the purpose of its use.
4. The desired outcome of patients tissues will return to normal structure and
function after two months of being discharged is unable to be evaluated.
However, I could say that is partially met because the interventions of
assessing the condition of the tissue (from what I could see without
removing abdominal dressing), assessing the characteristics of the incision
(could only assess cerebral incisions that has steri-strips on them but unable
to assess under abdominal dressing), assessing for elevate body

temperature, which my patient did not have, and identifying for signs of
scratching or itching, which my patient did not do, were al performed.
However, I did not perform any dressing changes to be able to maintain
sterile technique and also did not administer any antibiotics.

5. The desired outcome of patient verbalizes understanding of and

demonstrates ability to perform postoperative care after discharge before
clinical day is over/discharge will be measured by the patient verbalizing
that he understands the teachings of how to perform the abdominal dressing
changes after discharge and also by performing a return demonstration of
how to perform his own abdominal dressing change. Furthermore, this
outcome will also be measures on the patient/caretaker stating
understanding of the appropriate activities and when to seek medical
treatment. If the patient is unable to perform it himself, a family
member/caretaker can be the one to verbalize understanding of this
postoperative care and also be the one to do a return-demonstration of a
dressing change. I witnessed the nurse giving discharge instructions to the
daughter of the patient before he was discharged the same and only day I
cared for him, and the daughter stated she understood the instructions and
also signed the paper. I was unable to witness teaching or a returndemonstration of the abdominal dressing change.


6. The desired outcome of patient demonstrates positive health maintenance
behaviors as evidenced by keeping scheduled appointments, participating in
smoking or substance abuse programs, making diet and exercise changes,
improving home environment, and following treatment regimen will be
measured by determining if patient attends his scheduled appointments,
participates in a program to assist him in alcohol use cessation, and
determining if he makes diet/exercise changes, improves his home
environment, and if he follows treatment regimen after being discharged.
Because I was only assigned to this patient for one clinical day, I was unable
to measure this outcome; however, the daughter stated understanding of the
importance of her father attending his follow-up medical appointment. The
only intervention I was able to follow-up with myself was assess the hx of
other adverse personal habits, including smoking, obesity, lack of exercise,
and alcohol or substance abuse; however, I only obtained this hx via the
patients electronic and hard chart that stated he has a history of alcoholism
and liver cancer and that he continues to drink alcohol everyday.


Discharge Plan/Patient Teaching

1. Placement/type of dwelling: Home


2. Support systems: Wife, daughter, & grandson visited patient while I was assigned
to him and were also who patient was discharged to be taken home with.


3. Assistance needed with ADLs: Patient needs continuous supervision because of hx
of falls that have gone un-witnessed and lead to this hospitalization with the
implication of bilateral subdural hematomas. The patients daughter said that the
patient lives with his wife at home, but the wife is also older and apparently unable
to assist patient with ADLS as evidenced by fall history and also as stated by
daughter. The daughter said she would be moving in with the patient, her father, to
assist him with his ADLs at least until he returns to his previous state of health
before the un-witnessed falls. However, I believe the patient will need to have a livein caretaker if plans to live at home and not in a long-term care facility.


4. Equipment needs: Front-wheel walker, possibly a urinal or commode to allow for
patient to use restroom at night without having to get up and walk to bathroom to
help reduce fall risk, good lighting in home, including night lights, possibly fall
alarms of some sort for home if living with caretaker(s) that can be alerted of the
need for assistance, non-skid footwear to wear inside the home, non-skid surfaces to
be applied to bathtubs/showers and possibly a shower chair, needed supplies to
ensure rugs are secured to floors if decide not to remove them from the home if
currently have them, and some kind of alert necklace like Life Alert or something to
be worn at all times in case falls when no one is around and unable to get up.


5. Patient teaching:
a. How the patient prefers to learn: In Japanese but unable to ask him if he
prefers to be told or shown. However, I assume he would prefer to be told
over shown due to possibly decreased eyesight due to old age.

b. Barriers to learning: Primarily Japanese speaking, altered mental status,
dementia, old age.


c.

Topics to be addressed: Home fall safety, medications, diet (soft-textured

and thickened liquids), aspiration precautions, when to notify MD (s/s of
infection of incisions, PNA), alcohol consumption cessation, medical followup, to continue to cough & deep breathe, t continue to use incentive
spirometer, to always use front wheeled walker when ambulating, that
furniture needs to possibly be arranged in home differently so that high
traffic areas are free of clutter, especially the walkway to the restroom, that
bright lighting is essential, supervision is needed, etc.