Lisa Chee, Kapiolani Community College Student Nurse (NURS 360, Fall 2014)

1. Imbalanced Nutrition: Less than

Body Requirements
2. Infection/ Impaired Tissue
Integrity

Immobility
Imbalanced nutritional state
Impaired circulation
Stage II pressure ulcer to coccyx
area
Elevated WBC/ Neutrophils
Metronidazole 500 mg, PO, TID
Micafungin 100 mg, IVPB, daily
Nystatin, 1 application, topical, BID
Ceftriaxone 50 mL, IVPB, Q24H

3. Fatigue

Low RBC, H/H labs

Elevated RDW
Anemia
Sleep deprivation
Malnutrition

Bolus Jevity 1.2 via J-tube

Low consumption of AM meal: 20%
Poor intake/caloric count
Anemia, weakness, fatigue

s/p abdominal surgery

s/p Lt hip revision
PRN acetaminophen-codeine 12.5 mL
for moderate pain
PRN acetaminophen-codeine 25 mL
for severe pain

Fatigue, weakness
Decreased motivation
Occupational therapy

7. Impaired Physical Mobility

Clinical Medical Diagnosis
Perforated duodenal ulcer, GI bleed,
syncope, CHF, aFib, hypotension,
Post-op abdominal exploration, closure of
duodenal ulcer w/ omental patch

Musculoskeletal impairment
Decreased muscle strength
Prolonged bed rest
Fatigue, weakness
Physical therapy

Priority Assessments
Respiratory, abdominal, cardiovascular,
LOC, I&O, s/s bleeding or infection, pain,
abdominal surgical site, J-tube site, skin
integrity, oral mucous membrane

4. Pain

8. Self Care Deficit

5. Insomnia

Fatigue
Frequent daytime dozing
c/o difficulty falling asleep

6. Decreased Cardiac Output

h/o AFib
Vitals Q8H
HR: 72 (irregular)
BP: 108/58, hypotension
Fatigue , restlessness
Weak peripheral pulses
Anorexia
Dependent edema
Swollen hands & fingers
Distended abdomen
Felodipine CR, 5 mg, PO, daily
Furosemide (Lasix) 20 mg, PO,
daily
Daily weights