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Pain: Pt will have managed pain that is tolerable according to patient standards.

Fluid Electrolyte Imbalance: Pt will increase fluid intake and increase H&H before discharge. Risk for Bleeding: Pt will not have any active bleeding while on shift. Pt will ask for assistance and will call for help. Will assess dressing for intactness and drainage. Will monitor INR and PT labs strictly. Anxiety: Pt will have managed anxiety and will verbalize feelings of anxiety and will request PRN anti-anxiety medication as needed. Immobility: Pt will ambulate BID with forward wheel walker, and will rest in between as needed. Infection/Skin Integrity: Pt will be infection free before discharge. Pt will turn q2hours and will ambulate at least BID. Elimination: Pt will use bedside commode as needed and will request for help. Pt will have BM before discharge.

1. Administer PRN pain medication (Dilaudid PCA, morphine, Hydromorphone) 2. Pt teaching about PCA Dilaudid, and weaning off PCA to PO pain medication. 3. Reassess Pain q1hour 1. Monitor IV rate, Lactated Ringers 30ml/hr 2. Monitor daily changes in lab results 3. Offer hydration and healthy food options 1.Monitor daily lab values (PT and PTT, INR) H&H lab values 2.Assess dressings, drains, and tubes for active bleeding and notify MD if any drainage is abnormal. 3.Offer assistance to pt when ambulating and moving about to avoid damage to tissue and drains. 1. Use therapeutic communication and talk about issues at hand. 2. Administer PRN anxiety medication if needed (Ativan 2mg) 3. Explore coping mechanisms that help satisfy patient needs. 1. Assist pt with cough deep breathing exercises. 2. Assist pt with ambulating with walker BID, or more if tolerated 3. Encourage patient to be independent as much as possible and to strengthen muscles. 1. Monitor Vital signs q4hours or PRN 2. Monitor pt turning schedule if unable to turn self. 3. Ambulate pt BID at a minimal and assist PRN 1. Offer assistance to bedside commode, and work up to ambulating to restroom on own. 2. Administer PRN stool softeners 3. Increase dietary fiber and fluid intake

Evaluation: During the 2 days of care for this particular patient, I was able to help her ambulate multiple times to the restroom, and even get her out of bed and walk around the unit. The patient is currently waiting for transfer to the 5th floor rehabilitation center, where she can build up her strength and then be discharged home. 1.PAIN: Pt will have managed pain through use of the PCA pump, and asking for her PRN pain medication. Pt will verbalize pain tolerance and will reassess every hour. After two days of working with this patient, and use of the PCA pump, she was able to state her pain was well managed and that she no longer felt the need for the PCA, or even use of the PRN pain

medication. For this intervention, I feel that the goal was met and that the patient was stable and well educated on her problem at hand. Since the pain was well controlled, this goal and intervention was Met. 2. Fluid Electrolyte Imbalance: The goal for this intervention is to reestablish baseline H&H, and to prevent any dehydration or imbalance of electrolytes. For this intervention to work, I monitored her IV rate and tolerance, as well as monitoring daily labs. Pt is a Jehovahs Witness and will not accept any blood products. So for her H&H to go back to baseline, we will need to continue monitoring it, and offering other options. For this goal, it was primarily met, but still can have improvement before being discharged. 3.Risk for Bleeding: The goal for this intervention is make sure the pt does not have any active bleeding and to always be aware of her lab values. Because the pt will be going home with Coumadin, there needs to be a lot of pt teaching about the medication and about the signs and symptoms of bleeding. I believe that this goal was Met and that the pt fully understands the risk for bleeding, and has the ability to notify nursing staff for assistance. 4. Anxiety: Pt is very anxious and states she feels ugly with her back the way it was before. Pt seems to have some type of emotional trauma from before the surgery. However post-op, pt states she feels beautiful and that her back is like a normal persons back. She states she feels much better and that she can conquer the world now. For the goal of anxiety, I made sure to offer her the prn anti-anxiety medication, as well as discussing coping mechanisms, however the patient seemed well enough and did not need much assistance via teaching or medication. For this goal, I feel that it was met. 5. Immobility: The goal for this intervention is to increase patients daily ambulation to tolerated without pain, and with minimal assist so no bed sores develop or DVTs. Currently patient can move about her room without much assist and states pain while standing, but with use of the PCA shes fine. After day 2, she stated she no longer needs the pain medication, and was able to freely ambulate unassisted and state that she feels great. I feel that the goal of immobility was corrected and Met. 6. Infection/Skin Integrity: The goal for infection control and skin integrity is to monitor vital signs q4 hours and to ambulate the patient. With the 2 days of working with the patient, she had well-controlled pain and was able to ambulate with minimal assistance and was able to walk around the unit. Vital signs were kept up to date and monitored carefully and the pt did not develop any signs of new infection post op and was very happy to be able to walk again. For this goal and intervention, I feel it was Met. 7. Elimination: The issue of elimination surprisingly did not become a big issue. Since the patients pain was well tolerated and there was not that many PRN pain medications being given, she did not become constipated or have any bowel issues. Pt was able to ambulate to the bed side commode, and then even to the room restroom by end of shift second day post op. PRN stool softeners were given, and pt was able to void and stool freely and without any assistance. This goal was Met.

Discharge Plan/Patient Teaching: 1. Pt will be transferred to 5th floor rehab and will be assessed from there on. If completed, pt will be discharged home with follow up appointments. Pt will be discharged with forward wheel walker if needed. 2. Pt has good friend named Faith, who will be helping her at home when discharged. Pt is also active in a community church and will be happy to see them again upon discharge. 3. Pt will be discharged from 8Ewa with a walker, and will go to rehab in hopes of strengthening self and able to ambulate with minimal assistance and no assistive devices upon discharge. 4. Forward Wheel Walker to go with pt to rehab facility. 5. Patient Teaching: Learning is best done via verbal command and pictures. Current barriers to learning would be: Pt acts impulsively and is a polysubstance abuser and has history of altered mental status r/t drug abuse. May need further education and or rehab assistance with this. 6. Pt will be discharged to rehab facility and will be discharged with her current medications: (Gabapentin for nerve pain, Docusate sodium for stool softening, and PRN ibuprophen for pain). Pt wil also be on Coumadin and will need further teaching about the s/s of bleeding and the times when to seek medical attention. Pt will also need to have follow up with MD and get labs drawn for PT and INR. 7. Pt needs to set up a follow up appointment with doctor and will need to continue physical therapy and possibly occupational therapy if needed.

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