Jaclyn Hirohama

NURS360 Kuakini Clinical Group

4/2/15
Nursing Outcomes & Interventions
Desired Outcomes
1. Altered Nutrition/Fluid & Electrolyte
Imbalance AEB low potassium levels (2.7 mEq),
c/o nausea/vomiting following surgery, reduced
PO intake.
Patient will maintain potassium levels within
normal limits within 2 clinical shifts
o Potassium levels increased from 2.7
to 3.6 and remained WNL through
clinical shift
o No s/s of hypokalemia
Patient will tolerate clear liquid diet and will
not have nausea/vomiting within 2 clinical
shifts
o Tolerated clear liquids; PO intake
120 mL during clinical shift
o No c/o nausea, vomiting
2. Pain R/T post-operative surgical incision
Patient will report decrease in pain, at least
3/10 rating, during 2 clinical shifts
o Patient reported pain 2/10
o Refused pain medications

3. Skin Integrity/Infection R/T abdominal

surgical incision open to air
Patient will remain afebrile during 2 clinical
shifts
o Temperature: 36.1, 36.5 during
clinical shifts
Patient will remain free of infection at surgical

Interventions
1. Altered Nutrition/Fluid & Electrolyte
Imbalance
Monitor continuous IV fluid with
potassium additive.
Administer prescribed potassium
replacements as needed.
Monitor serum electrolytes (especially
K+) daily and as needed for
replacement.
Encourage patient to start clear liquids
slowly and as tolerated to prevent
nausea/vomiting.
Monitor patient for nausea/vomiting
and administer ondansetron as ordered
PRN.
Educate patient on reasons for clear
liquid diet.
2. Pain
Assess pain levels at rest and during
activity (quality, location, severity,
precipitating/relieving factors)
Encourage patient to report pain and
desire for PRN pain medication.
Administer PRN pain medication as
ordered.
Educate patient on preventive pain
control measures before activity.
Educate and teach patient on
nonpharmacologic pain control
measures (i.e. distraction, music
therapy, breathing techniques)
Evaluate patient response to pain
management techniques.
3. Skin Integrity/Infection
Monitor vital signs q4hrs and PRN
Educate patient of risk of post-op
infections
Assess and monitor abdominal wound
for approximation, redness, swelling,
drainage, pain

Jaclyn Hirohama
NURS360 Kuakini Clinical Group
4/2/15
incision site for 2 clinical shifts
o No signs of redness, swelling,
drainage
o Wound well-approximated

Provide wound care and dressing

changes per physician orders
Promote ambulation as early as
possible, with assistance
Provide skin care daily
4. Altered Elimination
Assess bowel sounds and abdominal
distention every shift
Monitor patient for urge to defecate
Promote physical activity to promote
bowel activity
Monitor urine output q4hrs and PRN
Encourage patient to increase intake of
liquids, within diet parameters.

4. Altered Elimination AEB no BM since

admission, risk for post-op urine complications.
Patient will pass soft, formed stool within 2
clinical shifts
o No BM during clinical shift
o Reports the urge to make BM
o Abdomen soft, nontender
o Bowel sounds present x4 quad
Patient will maintain urine output greater than
30 ml/hr within 2 clinical shifts
o UOP 350 ml during 1st clinical shift,
400 ml during 2nd clinical shift
o No c/o pain upon urination
5. Immobility AEB requests assistance with
5. Immobility
ambulation and positioning, uses walker for
Assess motor strength and ROM in
assistance, and slow gait.
upper and lower extremities.
Patient will maintain steady gait and ambulate
Assess gait and need for safety devices.
with assistance within 2 clinical shifts
Refer to physical/occupation therapy as
o Requested assistance with
needed.
ambulation and positioning
Encourage and facilitate early
o Worked with PT/OT
ambulation.
o Slow, steady gait with walker
Educate and encourage patient to call
o Patient expressed concerns about
for assistance with ambulation and
mobility at home after discharge
encourage use of assistive devices.
Allow the patient to perform tasks at
her own rate; do not rush the patient.
6. Safety AEB decreased vision, hx of
6. Safety
osteoarthritis, hx of mild gait disturbance, and
Perform physical assessment to
advanced age.
determine patients baseline functions.
Patient will demonstrate understanding of
Refer to physical/occupational therapy
safety risks and ask for assistance with ADLs
for evaluation.
within 2 clinical shifts
Encourage patient to use eyeglasses and
o Requested eye drops to increase
eyedrops before ambulating.
vision
Educate patient on safety risks in the
o No falls while ambulating
home (i.e. rugs
o Patient expressed concerns about
Place patient items within reach and
safety at home after discharge
answer call lights immediately.

Jaclyn Hirohama
NURS360 Kuakini Clinical Group
4/2/15
Encourage the patient to wear non-slip
socks when ambulating.

Jaclyn Hirohama
NURS360 Kuakini Clinical Group
4/2/15
Evaluation
Altered Nutrition/Fluid & Electrolyte Imbalance
The patient will maintain potassium levels within normal limits within 2 clinical shifts,
measured by serum potassium levels. This desired outcome was met by adding KCl to the
continuous IVF solution and administering IV potassium replacements.
The patient will tolerate clear liquid diet and will have no nausea/vomiting within 2
clinical shifts, measured by assessment and patient report. This desired outcome was met as
evidenced by no reports of nausea and no reports of emesis. Patient reports comfort and
satisfaction with clear liquids.
Pain
The patient will report decrease in pain, at least 3/10 rating on a numeric scale, during 2
clinical shifts. This desired outcome was met by assessing pain levels and behaviors associated
with pain. Patient reported pain 0/10 on a numeric scale and stated no desire for pain medication.
Skin Integrity/Infection
The patient will remain afebrile during 2 clinical shifts, measured by routine vital signs
assessment. The desired outcome was met by routine temperature values within normal limits.
The patient will remain free of infection at surgical incision site within 2 clinical shifts.
This was measured by abdominal assessment at the surgical site for swelling, drainage, pain, and
redness. The desired outcome was met as evidenced by abdominal incision site had no swelling,
no drainage, and slight erythema. Patient reported no discomfort and no pain.
Altered Elimination
The patient will pass soft, formed stool within 2 clinical shifts, measured by monitoring
and patient report. This desired outcome was not met as evidenced by patient reports of no
bowel movement.
The patient will maintain urine output greater than 30 ml/hr within 2 clinical shifts by
measuring urine. This desired outcome was met as evidenced by urine output measured greater
than 240 ml/8hr in each clinical shift.
Immobility
The patient will maintain steady gait and ambulate with assistance within 2 clinical shifts,
measured by assessment and assistance with ambulation. The desired outcome was met by
assisting patient with ambulation and assessing gait. Patient required assistive device when
ambulating, such as a walker or IV pole.
Safety
Patient will demonstrate understanding of safety risks and ask for assistance with ADLs
within 2 clinical shifts, measured by patients response. This desired outcome was met by the
patient verbalizing understanding of importance of safety. Patient expressed concerns of safety
since she lives at home alone and wanted to consider the option of short-term rehabilitation.

Jaclyn Hirohama
NURS360 Kuakini Clinical Group
4/2/15
Discharge Plan/Patient Teaching
After discussion with the patient and her two daughters, the expected discharge location
is expected to be a short-term rehabilitation center. She is widowed and currently lives at home
alone. Her daughters live in the mainland and are visiting to help care for the mother. They
cannot stay for an extended period of time, but have expressed flexibility in flying back to help
the patient after rehabilitation. In addition to her daughters, her support system consists of
friends, neighbors, and church members. Prior to her hospitalization, she used a cane for
assistance with ambulation. She may still need to use assistive devices when ambulating, such as
a walker, cane, non-slip shoes, etc. She is independent of ADLs, like feeding, putting makeup
on, using the bathroom, cooking, etc. One concern may be showering, which may require use of
a bath chair and non-slip strips in shower. Upon discharge teaching, the patient prefers verbal
teaching due to poor eyesight and need for eyeglasses makes it slower to read. There are no
other barriers to her learning. She demonstrates a readiness to learn and verbalizes
understanding of teachings. Discharge teaching must include signs and symptoms of postoperative complications, signs and symptoms of infection, safety issues, medication education,
health promotion behaviors (constipation, diet, skin care), and medical follow-up.

Jaclyn Hirohama
NURS360 Kuakini Clinical Group
4/2/15
References
Copstead, L., & Banasik, J. (2013). Pathophysiology. St. Louis, MO: Saunders.
Gulanick, M., & Myers, J. L. (2014). Nursing Care Plans. Philadelphia, PA: Elsevier.
Ignatavicius, D. D., & Workman, M. L. (2013). Medical-Surgical Nursing: Patient-Centered
Collaborative Care. St. Louis, MO: Elsevier Saunders.