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NURSING MANAGEMENT

Actual Nursing Care (SOAPIE)

June 20, 20102-10 shift

PROBLEMS:

#1 INEFFECTIVE AIRWAY CLEARANCE R/T RETAINED SECRETIONS

#2 HYPERTHERMIA#3 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 vitalsigns 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

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>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

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June 21, 201010-6 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 secretionsP> After 4 hours of nursing intervention, patient will have a patent airway and will be

able to expectorate secretions

I> Assessed patient



>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



>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

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June 22, 20102-10 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




>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

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June 23, 20106-2 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 38.1O

C / 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

OC

I> Assessed patient



>Regulated IV fluids as ordered

>TSB done

> Nebulization done c/o RT




>Mechanical ventilator settings checked>Suctioned oral and ET secretions

>Flushing of NSS done

>Oral care done

>Glucose monitoring done

>Checked NGT patency

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>OF given



>Due needs attended

E> Goal not met as evidenced by patients temperature is only 37.9C

R> Reinforced previous intervention

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