SIM Henry Williams

SIM Henry Williams

1. Anxiety; AEB restlessness, fatigue; RT Hospitalization, condition, diagnosis

   • Assessments:
     • 60 sec scan
       • VS, pain PQRST, AOx4
         • assess level of anxiety
           • Reassess after alt therapy or med admin
   • Interventions:
     • assess level of anxiety/ to determine level of care
       • rule out withdrawal as cause/ to gain knowledge about pt needs
         • identify cause of anxiety/ to know the root cause
           • use massage therapy/ to reduce anxiety
     • use therapeutic touch & healing techniques/ to reduce anxiety
     • use aroma therapy/ to reduce anxiety
     • explain procedures in calm clear manner/ to reduce anxiety
     • encourage patient to open up about anxieties & fears/ to gain understanding
     • collaborate with health team for coping mechanisms/ educate pt
     • administer meds as needed/ to reduce anxiety

2. Risk for unstable blood glucose; AEB weight loss, inadequate dietary intake, inadequate physical activity

   • Interventions/ Rationales:
     • obtain blood glucose before meals and snacks or every 4-6 hr if the client not receiving nutrition/ useful in adjusting premeal insulin doses
     • monitor signs and symptoms of hypoglycemia/ for safety of pt
     • monitor signs and symptoms of hyperglycemia/ to avoid complications
     • ensure pt is receiving adequate fluids and nutrition/ to avoid ketoacidosis or other life threatening complications
     • lower stress levels/ avoid rises in blood glucose
     • evaluate clients med regimen for meds that can alter blood glucose/ make sure other meds are not causing the problem
     • collaborate with dietitian/ to ensure adequate nutrition & understand glycemic control
     • encourage activity and ambulation as tolerated or rotate pt/ to avoid glucose intolerance and pressure ulcers
       • patient education on diabetes mellitus and blood glucose testing/ ensure pt knowledge on regimen & how to test
     • patient education on diet/ ensure pt knows how diet will affect blood glucose & glycemic control
     • administer diabetic meds as ordered/ to control glucose level
   • Assessments:
     • 60 sec scan
       • VS, pain PQRST, AOx4
         • blood glucose testing
           • assess for signs of hypoglycemia/ hyperglycemia
             • assess I&Os

3. Ineffective airway clearance; AEB excessive mucous production, O2 88, RR 26, restlessness; RT COPD

   • Meds: albuterol sulfate, montelukast sodium
   • Labs: arterial blood gas (pH, PCO2, HCO3, PO2)
   • Interventions/ Rationales:
     • auscultate breath sounds every 1-2 hr/ listen for fluid or obstruction
     • monitor resp patterns (rate, depth, effort)/ to see if breathing becomes easier or labored
     • monitor blood gas values & PO2/ to know if pt is getting enough oxygen
     • position client in upright position/ to optimize respiration
     • helping client use forced expiratory technique- "huff cough"/ help clear secretions
     • administer resp meds as ordered/ to improve ease of breathing
     • encourage activity and ambulation as tolerated/ body movement helps mobilize secretions
     • encourage fluid intake of up of 2500 ml/day within cardiac or renal reserve/ help loosen & move mucous
     • observe sputum, noting color, odor, volume/ helps indicate if sputum is normal or abnormal
     • suction airway as needed/ to keep airway clear
   • Assessments:
     • 60 sec scan
       • VS, pain PQRST, AOx4
         • lung sounds, RR effort & depth, PO2
           • assess Cough ability & Sputum
             • Reassess after med administration

4. Master set of Priority interventions:

   • position client in upright position/ to optimize respiration
     • auscultate breath sounds every 1-2 hr/ listen for fluid or obstruction
       • monitor resp patterns (rate, depth, effort)/ to see if breathing becomes easier or labored
         • monitor blood gas values & PO2/ to know if pt is getting enough oxygen
           • observe sputum, noting color, odor, volume/ helps indicate if sputum is normal or abnormal
             • administer resp meds as ordered/ to improve ease of breathing
               • evaluate clients med regimen for meds that can alter blood glucose/ make sure other meds are not causing the problem
                 • obtain blood glucose before meals and snacks or every 4-6 hr if the client not receiving nutrition/ useful in adjusting premeal insulin doses
                   • administer diabetic meds as ordered/ to control glucose level
                     • monitor signs and symptoms of hyperglycemia/ to avoid complications
                       • encourage fluid intake of up of 2500 ml/day within cardiac or renal reserve/ help loosen & move mucous
                         • encourage activity and ambulation as tolerated/ body movement helps mobilize secretions
                           • encourage activity and ambulation as tolerated or rotate pt/ to avoid glucose intolerance and pressure ulcers
                             • helping client use forced expiratory technique- "huff cough"/ help clear secretions
                               • suction airway as needed/ to keep airway clear
                       • ensure pt is receiving adequate fluids and nutrition/ to avoid ketoacidosis or other life threatening complications
                     • monitor signs and symptoms of hypoglycemia/ for safety of pt
             • explain procedures in calm clear manner/ to reduce anxiety

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