Problem #1: Impaired spontaneous ventilation and ineffective airway clearance

General Goal: Adequate ventilation and effective airway clearance

Predicted Behavioral Outcome Objective (s): SPO2 will remain > 95% on DOC.

Nursing Intervention Patient Response

1. Continuous pulse ox 1. SPO2 remained 98%

2. Suction ETT PRN 2. Moderate thick brown sputum

3. Assess gag reflex 3. Absent during mouth care and ETT

suctioning

4. Draw and check ABG results 4. Comp metabolic acidosis, PO2 103.6

5. Monitor vent settings and RR 5. A/C, rate 18, TV 500, FiO2 55%,
PEEP 8.0; RR 18-27

6. Mouth care 6. No gag reflex, moderate amount of

clear secretions suctioned

7. Assess perfusion 7. Cap refill < 3 sec, skin warm with

appropriate/pink color, pulses 2-3+

8. Auscultate LS 8. Clear, diminished bilat lower lobes

Evaluation of outcome objectives: Met- SPO2 remained 98% throughout DOC.

Problem #2: Imbalanced fluid volume
General Goal: Balanced fluid volume / adequate circulation

Predicted Behavioral Outcome Objective (s): MAP will remain > 65 on DOC.

Nursing Intervention Patient Response

1. Hourly VS (automatic NIBP) 1. Ranged from 102/66 (MAP 70) to

173/87 (MAP 127); HR 93-105

2. D5 ½ NS IVF @ 150 mL/hr 2. MAP remained > 65; blood glucose

elevated (see ND #5)

3. Assess skin for signs of dehydration 3. Good skin turgor, moist mucous
membranes, color pink/appropriate,
warm and dry

4. Check labs indicating fluid volume 4. Na 145, Cl 111, Albumin 4.3

status

5. I&O 5. UO 285 mL total (clear, straw), med

size liquid brown bm, cumulative
fluid balance +1610.9 day prior

6. Assess pulses 6. < 3 s all extremities

7. Check capillary refill 7. Generalized trace edema, LS

clear/diminished, see VS and UO
above

8. Assess signs of fluid retention or 8. Radial 3+ bilat, pedal 2+ bilat

third spacing

Evaluation of outcome objectives: Met- MAP remained > 65 on DOC.

Problem #3: Impaired cerebral tissue perfusion
General Goal: Adequate cerebral tissue perfusion

Predicted Behavioral Outcome Objective (s): Pt will be free from seizures on DOC

Nursing Intervention Patient Response

1. Assess LOC (baseline and reassess) 1. GCS 3 throughout DOC,

unresponsive to pain

2. Assess gag reflex 2. Absent gag reflex

3. Check pupillary response to light 3. Sluggish, equal, round, 3 mm

4. Keppra 1000 mg IVP over 3 mins 4. Pt remained in status epilepticus

5. Fosphenytoin 100 mg IVPB 5. Seized during administration: R

facial twitch, L gaze, L arm jerk

6. Midazolam 10 mg/hr IV PRN for 6. Pt continued to seize ~q15-30 min

seizure activity for 1 min at a time

7. Ensure patient safety with seizure 7. Pt was free from injury caused by
pads/pillow on L side seizures

8. Cluster care 8. Pt. remained in status epilepticus,

seized during ABG draw and blood
glucose checks

Evaluation of outcome objectives: Not Met- Pt. remained in status epilepticus and seized
~q15-30 mins on DOC.
Problem #4: Electrolyte imbalance
General Goal: Balanced electrolytes, absence of arrhythmias

Predicted Behavioral Outcome Objective (s): Pt will be free of arrhythmias on DOC

Nursing Intervention Patient Response

1. Draw and check labs 1. Na 145, K 4.7, Cl 111, Ca 8.0, Mg

2.4

2. Continuous EKG 2. NSR/sinus tachy baseline on DOC

3. D5 ½ NS IVF @ 150 mL/hr 3. SS adequate hydration: good skin

turgor, moist mucous membranes,
strong pulses, etc (see ND # 2)

4. IV KCl 20 mEq, 10 mEq/hr IVPB 4. SR; Absence of arrhythmias

associated with hypokalemia
(U-wave, PVC’s)

5. Continue to manage insulin drip (K 5. SR; Absence of arrhythmias

is already 4.7 and we are giving associated with hyperkalemia
more) (peaked T waves, widened QRS)

6. Suction only PRN, < 15 s passes 6. NSR while suctioning

7. Monitor urine output 7. 0700-1100: 75, 75, 100, 10, 25

8. Magnesium Sulfate 2000 mg IVPB 8. SR; Absence of arrhythmias

associated with hypokalemia

Evaluation of outcome objectives: Met- Pt remained in SR on DOC.

Problem #5: Unstable blood glucose
General Goal: Stable blood glucose

Predicted Behavioral Outcome Objective (s): Blood sugar will be < 250 on DOC.

Nursing Intervention Patient Response

1. POCT blood sugars qh 1. 0700-1100: 277, 285, 321, 267, 293

2. Manage insulin drip 2. Fluctuations in blood glucose levels

3. D5 ½ NS IVF @ 150 mL/hr 3. Blood glucose remained > 250

4. NPO diet 4. Blood glucose remained > 250

5. Monitor urine output for polyuria 5. 285 mL total

6. Draw and check ABG’s 6. pH 7.39, PCO2 32.6, HCO3 19.4

7. Check labs: glucose, anion gap, beta 7. Glucose 321, anion gap 18, beta
hydroxybutyrate, venous CO2 hydroxybutyrate > 4.5, CO2 16

8. Assess for Kussmaul’s/rapid 8. RR 18-27

respirations

Evaluation of outcome objectives: Not met- Blood glucose ranged from 267-321 on DOC.
Problem #6: Infection
General Goal: Pt free of infection

Predicted Behavioral Outcome Objective (s): Temp will be 97.6-99.6 on DOC.

Nursing Intervention Patient Response

1. Check pt temp 1. 100.3 F

2. Administer Acyclovir 950 mg IVPB 2. Elevated temp, skin warm and dry to
palpation

3. Administer ampicillin 2000 mg 3. Elevated temp, skin warm and dry

IVPB

4. Administer ceftriaxone 2000 mg IVP 4. Elevated temp, skin warm and dry
over 2 mins

5. Assess peri-anal abscess 5. Purulent drainage, open and red,

surrounding skin warm but intact,
OTA

6. Check and change frequently for 6. BM x1 medium size, loose

bowel incontinence

7. Check WBC count 7. Trending down: 15.8-11.6

8. Assess triple lumen site 8. Dressing clean dry and intact,

infusing, skin intact with no redness
or irritation

Evaluation of outcome objectives: Not met- Temp of 100.3 (remained > 99.6) on DOC.
Problem #7: Risk for allergic reaction
General Goal: Prevention of allergic reaction

Predicted Behavioral Outcome Objective (s): Pt will be free from rash/hives and tachypnea
on DOC.

Nursing Intervention Patient Response

1. Verify order with the physician 1. Verified that benefits outweigh the
before administration risk

2. Assess skin (baseline and after 2. Smooth, warm, dry, and appropriate
administration of penicillin abx) color; no change from baseline

3. Monitor RR 3. 18-27 on DOC, but remained 18

before and after administration

4. Monitor HR 4. HR ranged from 93-105 throughout

DOC, no significant change after
administration

5. Auscultate LS 5. Clear/diminished, no change from

baseline

6. Assess for new swelling 6. Generalized trace edema; no change

from baseline

7. Check pt temp 7. 100.3 before administration, no

significant change

8. Monitor BP 8. 141/78 before, 102/66 after (not

immediately after; likely dehydration
r/t DKA)

Evaluation of outcome objectives: Met- Pt was free from rash and hives with RR 18 on DOC.
Problem #: Impaired Communication
General Goal: Improved communication

Predicted Behavioral Outcome Objective (s): Pt will withdraw from pain on DOC.

Nursing Intervention Patient Response

1. Assess LOC baseline 1. GCS 3, does not follow commands

2. Reassess GCS throughout DOC 2. GCS remained 3 throughout DOC

3. Try nail bed pressure 3. No response

4. Use sternal rub if nail bed pressure 4. No response

doesn’t elicit a response

5. Talk to the patient/offer emotional 5. No response: no movement, facial

support expression, change in HR or RR

6. Manage seizures (see ND #3) 6. Patient remained in status epilepticus

on DOC

7. Cluster care 7. Pt remained in status epilepticus on

DOC, seized during ABG draw and
blood glucose checks

8. Check pupillary reaction to light 8. Pupils sluggish, equal, round, 3mm

Evaluation of outcome objectives: Not met- Pt was unresponsive to pain on DOC (GCS 3).