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formerly had COVID-19

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Provide information about additional or outside learning resource (rationale: promotes ongoing learning after discharge)

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Assist the client to identify learning goals and measurable outcomes (rationale: helps to frame or focus content to be learned and provides a measure to evaluate the learning process (Unbound Medicine, 2022)

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I advocated or pt on Feb. 17th and the physician addressed pt's request up AM rounds on Feb 18th.

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GOAL: Pt will explicitly state that she is satisfied with education provided and has enhanced self-efficacy prior to discharge.

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Readiness for Enhanced Education r/t lifestyle post nephrectomy aeb pt requesting information

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Readiness for Enhanced Education r/t lifestyle post nephrectomy aeb pt requesting information

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GOAL MET: pt's pain manageable with dilauded and Tylenol. Pt was discharged on Feb. 18th, 2022 with this regimen. Next steps: keep adjusting this regimen and inform pt that opiods cause constipation

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Discuss pt's reports/perceptions of breathing ease (rationale: a range of symptoms might be stated) (Unbound Medicine, 2022d)

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Encourage frequent position changes and deep breathing and coughing exercises (rationale: promotes optimal chest expansion, mobilizes secretions, and oxygen diffusion) (Unbound Medicine, 2022d)

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Assess presence of conditions that could be causing impaired gas exchange (anemia, immobility, pain) (Rationale: impaired gas exchange can be related to many factors) (Unbound Medicine, 2022d)

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Supportive daughter

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Impaired Gas Exchange r/t lung fibrosis from previous COVID-19 aeb SPO2 <91 OD

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Impaired Gas Exchange r/t lung fibrosis from previous COVID-19 aeb SPO2 <91 OD

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PT will visit pt in the community

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Creatine = 131
Glomerular Filtration Rate =

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Determine how MJ perceives and manages solitude (rationale: pt may view solitude and positive or sad; therefore, this directs precision of interventions) (Unbound Medicine, 2022c)

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Identify patient's strengths (rationale: empowers pt and also prompts ideas for connecting with others) (Unbound Medicine, 2022c)

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Note presence and proximity of significant others (rationale: determines if family is available to assist with care) (Unbound Medicine, 2022c)

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CPAS referral

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Determine and treat underlying cause of pain (rationale: maximizes potential for mobilization) (Unbound Medicine, 2022b)

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Evaluate and track degree and presence of pain upon mobilizing (rationale: determines effectiveness of analgesic regimen) (Unbound Medicine, 2022b)

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Convey empathy by acknowledge and validate pain (Rationale: reduces defensiveness, promotes trust, and enhances cooperation with regimen) (Unbound Medicine, 2022a)

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Ascertain pt's goal for pain (e.g., would they be satisfied with 1 pain) (Rationale: 0 pain might not be achievable for the pt but sufficient discomfort could be alleviated by bringing the pain down) (Unbound Medicine, 2022a)

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Evaluate pain characteristics and intensity 2x per day (1-10, PQRST) (Rationale: creates baseline to evaluate whether pain is becoming worse, staying the same, or getting better) (Unbound Medicine, 2022a)

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https://nursing.unboundmedicine.com/nursingcentral/view/nurses-pocket-guide/2819083/all/acute_Pain?q=acute+pain

https://nursing.unboundmedicine.com/nursingcentral/view/nurses-pocket-guide/2819106/all/impaired_physical_Mobility#4.0

https://nursing.unboundmedicine.com/nursingcentral/view/nurses-pocket-guide/2819051/all/risk_for_Loneliness?q=for+loneliness+risk

https://nursing.unboundmedicine.com/nursingcentral/view/nurses-pocket-guide/2819379/all/impaired_Gas_Exchange?q=breathing

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Discharge GOAL: Pt will explicitly have state having adequate supports in the community prior to discharge.

GOAL MET! February 17th, as pt stated she was happy with the supports she will receive when she returns home

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Discharge Goal: Pt will mobilize as tolerated once per day (e.g., to shower, or for a short walk) and explicitly state pain is manageable prior to discharge

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Discharge Goal: Pt will explicitly having adequate analgesia prior to discharge. This will be achieved via thorough pain assessments

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Chronic Pain r/t carcinoma aeb pt reports of pain pre and post surgery

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Chronic Pain r/t carcinoma aeb pt reports of pain pre and post surgery

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Risk for loneliness r/t discharge aeb pt reporting limited support at home

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Impaired physical mobility r/t pain aeb pt reports of severe pain upon mobilization

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Impaired physical mobility r/t pain aeb pt reports of severe pain upon mobilization

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right-sided