Key Problem: Key Problem:
Key Problem: Impair Gas Exchange Acute Pain
Risk of infection
Supporting Data: Supporting Data:
Supporting Data: Born w/ Cleft lip & palate Rt. Ear plastic
Post-op day 2 Continuous pulse ox. reconstruction.
Keeps digging at head wrap HOB elevated to 30- Motrin Q6H ATC
around affected ear. degrees. Tylenol Q6H, given 3
Rt. Head/scalp JP drain Race epi. given for hours b/w each dose of
Immunocompromised congestion. Motrin.
while taking Decadron. Positive for Rhinovirus Oxycodone PRN Q4H
Positive for Rhinovirus Decadron 4mg BID Morphine PRN Q6H
Inspiratory stridor since Pulls at head wrap when in
birth. discomfort
Key Problem:
Patient/Family Anxiety
Key Problem:
Supporting Data: Imbalanced nutrition: less
Inspiratory stridor louder Reason for Needing Health Care than body requirements
than usual. Microtia of Rt. Ear
Pt. doesn’t verbally Supporting Data:
communicate his pain. Key Assessments: Emesis overnight 10/23/19
Mother believe pt is on the Pain assess/reassessment <5 % for height and weight
Autism Spectrum. Drainage at site of repair on growth chart.
Mother stays @ bedside Parent education on D/C follow-up Hx of J-tube
Cognitive delays Vital signs; RR/effort/quality Needed NG-tube feed of
Pt. tugs at head wrap breastmilk in 2014.
Pt is hearing & speech Hx of GER
impaired. Hx of cleft lip & palate
DMD gene X-linked
Key Problem: recessive muscular
Key Problem: Hearing Impairment dystrophy called Duchenne
Impaired Skin integrity & Becker
Supporting Data:
Supporting Data: Born w/ Microtia of Rt. ear
Slight blood-tinged Mother says pt is used to Key Problem:
drainage. sleeping on his right side Speech Impairment
Pt. removed head wrap (affected ear) so that his
Edema around Rt. ear left ear was up while he Supporting Data:
was sleeping so he could Pt. doesn’t verbalize his
hear noises. pain.
Must sleep on back or Lt. Mother believes pt is in the
ear to prevent injury to Autism Spectrum.
newly constructed Rt. ear. Born w/ micrognathia
(small jaw)
Problem # 1: Impaired Gas Exchange
General Goal: Monitor continuous pulse ox, keep HOB elevated to promote ventilation.
Predicted Behavioral Outcome Objective (s): The patient will show no signs of respiratory
distress during shift on 10/24/19.
Nursing Interventions Patient Responses
1. RR w/in normal limits (12-24) 1. RR = 17 breaths per minute
2. Keep HOB elevated 2. No use of accessory muscle w/ breathing effort
3. Give Decadron 4 mg BID 3. Pt had expiratory wheezes d/t congestion; + for Rhinovirus
Evaluation of outcomes objectives:
Pt did not have any signs of respiratory distress, no use of accessory muscles. I was able to hear expiratory
wheezes in both upper lobes of the lungs upon auscultation. HOB was maintained and supported proper
ventilation of a normal respiratory rate of 17 breaths per minute. Outcomes met.
Problem # 2: Imbalanced Nutrition, Less Than Body Requirements
General Goal: Increase intake of fluids/all meals, report any diarrhea, nausea or vomiting.
Predicted Behavioral Outcome Objective (s): The patient will consume at least 75% of meals
during shift on 10/24/19.
Nursing Interventions Patient Responses
1. Measure intake of all meals 1. Pt consumed almost entire meal during lunch
2. Administer Zofran PRN nausea 2. No nausea was reported during shift
3. Assess dietary preferences 3. Pt likes Oreos and snacked on them during shift
Evaluation of outcomes objectives:
Pt met outcomes of eating at least 75% of meals during shift. The patient reported nausea during the night on
10/23/19. However, no nausea was reported during shift on 10/24/19, so no administration of Zofran was
needed. Outcomes met.
Problem # 3: Risk of Infection
General Goal: No temperature or redness around surgical site.
Predicted Behavioral Outcome Objective (s): The patient will show no S/S of acute infection (i.e.
fever, redness, inflammation, heat) during shift on 10/24/19.
Nursing Interventions Patient Responses
1. Monitor temperature 1. Pts fever was 36.8 degrees C (98.2 degrees F) normal
2. Assess Rt. ear for swelling/redness 2. Slight redness and edema around Rt. ear
3. Assess Rt. ear for drainage 3. Scant amount of blood-tinged drainage on pillow noted
Evaluation of outcomes objectives:
The patient was Rt. ear reconstruction surgery port-op day 2 with little to no signs of acute infection. The
patient displayed no fever. There were no blood labs of a CBC in patient chart to assess WBC count to see if
there was an increase in levels. Patient was discharged on 10/24/19. Outcomes met.
Problem # 4: Acute Pain
General Goal: No S/S of pain or discomfort using numeric scale and FLACC scale.
Predicted Behavioral Outcome Objective (s): The patient will report a pain level <7 using
numeric scale of 0-10, with ‘0’ being no pain and ‘10’ being the highest pain, and score FLACC
scaled <6 during shift on 10/24/19.
Nursing Interventions Patient Responses
1. Give Motrin @ 3 pm for ATC management. 1. Motrin given at 4pm b/c pts grandma said to let him sleep
2. Assess pain using numeric scale or FLACC 2. Pt did not verbalize numeric pain level; FLACC score ‘0’
3. Reassess pain 30 mins. after giving Motrin 3. Pt was too drowsy to verbalize pain level; FLACC = 0
Evaluation of outcomes objectives:
The patient was receiving ATC pain management b/w Motrin and Tylenol. Pt was drowsy and sleepy during
shift to verbalize any type of pain level using 0-10. FLACC scale scoring of 0. Outcomes met.
Problem # 5: Impaired Skin Integrity
General Goal: Keep skin around surgical site clean and dry, no irritation.
Predicted Behavioral Outcome Objective (s): The patient will keep surgical site clean and dry
during shift on 10/24/19.
Nursing Interventions Patient Responses
1. Monitor drainage color/amount 1. Scant amount of blood-tinged drainage on head wrap and pillow.
2. Ensure pt does not lay on affected ear 2. Pt slept on Lt. ear (unaffected ear)
3. Change head wrap PRN 3. Pt ripped off head wrap; residents kept it off d/t discharge
Evaluation of outcomes objectives:
Not much drainage was coming out of surgical site, scant amount noted on pillow. Residents did not find it
necessary to put on a new head wrap b/c the pt was being discharged. Outcomes met.
Problem # 6: Patient/Family Anxiety
General Goal: Keep pt calm, decreased signs of anxiety from pt. Answer any questions and
provide any questions the mother may have.
Predicted Behavioral Outcome Objective (s): The patient will no signs of increased anxiety (i.e.
trouble sleeping, sweating, jitters, nausea or vomiting, during shift on 10/24/19.
Nursing Interventions Patient Responses
1. Monitor sleeping patterns 1. Pt napped during entire shift to catch up on lack of sleep night before.
2. Administer Ativan PRN 2. No Ativan administration necessary during shift
3. Provide written D/C instructions 3. Mother was given instruction; no questions w/ D/C papers
Evaluation of outcomes objectives:
The patient spent most of the shift sleeping since he had a rough night on 10/23/19 d/t nausea, pain and
anxiety. No reports of nausea, vomiting, jitters or sweating noted upon assessment during shift. Outcomes met.
Problem # 7: Hearing Impairment
General Goal: Ensure to talk to patient on left side into his good ear.
Predicted Behavioral Outcome Objective (s): The patient will respond to questions and
communication from student nurse during shift on 10/24/19.
Nursing Interventions Patient Responses
1. Ensure pt sleeps w/ good ear UP 1. Pt slept on Lt. ear during shift
2. Make eye contact w/ communication 2. Pt was drowsy during shift and did not speak
3. Use mother to help communicate to pt 3. Pt was easier to arouse when mother was present
Evaluation of outcomes objectives:
D/T microtia of the Rt. ear, the pt has a history of hearing impairment. The pt is used to sleeping on his right
ear, with the left ear facing upwards in order to hear noises during the night. The pt was difficult to arouse d/t
the inability to sleep on his Rt. ear, with his good ear being put against the pillow. Outcomes partially met
because the pt was only arousable when the mother was present.
Problem # 8: Speech Impairment
General Goal: Encourage the patient to verbalize any discomfort, use mother to help
communicate.
Predicted Behavioral Outcome Objective (s): The patient will attempt to verbally communicate
w/ student nurse during shift on 10/24/19.
Nursing Interventions Patient Responses
1. Ask questions regarding pain, N/V, etc. 1. Pt was drowsy during shift and did not communicate pain
2. Use mother to assist in communication 2. The pt told mom he wanted to go home when being D/C
3. ID non-verbal cues of discomfort (i.e. guarding) 3. No non-verbal cues noted; pulling at head wrap occurred
Evaluation of outcomes objectives:
The pts mother believes the pt is autism spectrum, which could be a reason for the pt to be non-verbal w/
others that he is unfamiliar with. I do his speech impairment obstructed the process of proper pt care, for
example the pt would not verbalize name and DOB w/ med pass. Outcomes not met.
