NUR 171

Supportive Educative Nursing

Comprehensive Nursing Care Plan

Sarah Russell
Name

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 Priority Nursing Diagnosis List
Problem: Impaired Gas Exchange
Etiology: r/t COPD and CHF____________________________________________________
Signs & Symptoms: aeb Decreased O2 saturation; labored breathing; SOB__________________

Problem: Activity Intolerance

Etiology: r/t COPD, CHF, and sedentary lifestyle
Signs & Symptoms: aeb Decreased O2 saturation with activity; exertional dyspnea; fatigue; weakness

Problem: Readiness for enhanced Knowledge

Etiology: r/t Behaviors congruent with expressed knowledge; describes previous experiences pertaining to the topic; explains knowledge of the
topic; expresses an interest in learning
Signs & Symptoms: aeb Verbalizes maintenance of O2 saturations by adjusting mask and deep breathing

Problem: Fatigue

Etiology: r/t Inability to restore energy even after sleep; increase in physical complaints; increase in rest requirements; lack of energy; lethargic;
tired
Signs & Symptoms: aeb Anemia; COPD; CAD; poor physical condition

Problem: Decreased Cardiac Output

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Etiology: r/t Arrhythmias; bradycardia; electrocardiographic changes; palpitations; tachycardia
Signs & Symptoms: aeb AFIB; pulmonary HTN

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 Priority #1 Nursing Care Plan
Nursing Expected Nursing Interventions Rationale Evaluation of
Diagnosis Outcomes Evidence-based? Interventions
P: Impaired gas Client will: Verbalize Assess: Monitor respiratory rate, Rationale: A study demonstrated Goal met aeb assessment of

exchange understanding of depth, and ease of respiration. that when the respiratory rate respiratory rate did not exceed 30
oxygen Watch for use of accessory exceeds 30 breaths/min, along breaths/min.
supplementation and muscles and nasal flaring (Ackley with other physiological
r/t other therapeutic & Ladwig pg. 375). measures, a significant
interventions. cardiovascular or respiratory
Maintain O2 sats @ alteration exists (Ackley & Ladwig
>90%, monitor O2 sats, pg. 375).
E: COPD and CHF continue to wear O2 Treat: Position the client in a Rationale: Evidence shows that Goal met aeb when client was

S: aeb decreased O2 mask. semi recumbent position with the mechanically ventilated clients placed in a semi-fowlers position

sat, labored breathing, head of the bed at a 30- to 45- have decreased incidence of VAP O2 saturation was maintained.

SOB degree angle to decrease the if the client is placed in a 30- to

aspiration of gastric, oral, and
nasal secretions (Ackley & Ladwig
pg. 375).
Teaching: Instruct the family
regarding home oxygen therapy if
Evaluation of ordered (e.g., delivery system,
expected
liter flow, safety precautions,
outcomes
Goal not met aeb O2 number of tanks needed) (Ackley
& Ladwig pg. 378).
45- degree semi recumbent
position as opposed to supine
position (Ackley & Ladwig pg.
375).
Rationale: Long-term oxygen Goal not met aeb client unable to
therapy can improve survival, return home.
exercise ability, sleep, and ability
to think in hypoxemic clients
(Ackley & Ladwig pg. 378).

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 saturation could not be Discharge: Reinforce the
maintain above 75%. importance of therapeutic
interventions. Teach the client
relaxation techniques to help
reduce stress responses and panic
attacks resulting from dyspnea
(Ackley & Ladwig pg. 378).
Rationale: A study demonstrated Goal not met aeb music was not
that use of music along with the available in the clients room.
resting period was effective in
relieving anxiety and exercise-
induced dyspnea in clients with
COPD (Ackley & Ladwig pg. 378).

Priority #2 Nursing Care Plan

Nursing Expected Nursing Interventions Rationale Evaluation of
Diagnosis Outcomes Evidence-based? Interventions
P: Activity Client will: Assess: the client daily for Rationale: A study utilizing Goal partially met aeb client was
Participate in
Intolerance appropriateness of activity and tomography demonstrated assessed daily for appropriateness
prescribed physical
activity with bed rest order. Mobilize the client significant decreased strength in of activity and bed rest order.
r/t appropriate
as soon as it is possible (Ackley & the hip, thigh, and calf muscles in Client was unable to mobilize
E: COPD, CHF and changes in heart
sedentary lifestyle rate, blood Ladwig, 2014 pg.121). elderly orthopedic clients, as well upon assessment.
pressure, and
as bone mineral loss with
breathing rate:
maintain monitor immobility (Ackley & Ladwig,
patterns (rhythm
2014 pg.121).

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S: aeb decreased and ST segment) Intervene: Allow for periods of
within normal
oxygen saturation rest before and after planned
limits.
with activity exertion periods such as meals,
baths, treatments, and physical
activity (Ackley & Ladwig, 2014
pg.123).
Evaluation of Teaching: Instruct and assist a
expected COPD client in using conscious,
outcomes controlled breathing techniques
Goal not met aeb client during exercise, including pursed
did not participate in lip breathing, and inspiratory
any activity. Client was muscle use (Ackley & Ladwig,
unable to maintain O2 2014 pg.122).
saturation with any Discharge: Allow terminally ill
movement. clients and their families to guide
care (Ackley & Ladwig, 2014
pg.124).
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Rationale: Both physical and
emotional rest helps lower arterial
pressure and reduce workload of
the myocardium (Ackley &
Ladwig, 2014 pg.123).
Rationale: A systematic review
found pursed lip breathing
effective in decreasing dyspnea
(Ackley & Ladwig, 2014 pg.122).
Rationale: Control by the client
or family respects their autonomy
and promotes effective coping
(Ackley & Ladwig, 2014 pg.124).
Goal met aeb client was given
time to nap before and after
meals, baths, and treatments.
Goal partially met aeb client was
reminded when O2 sats
decreased to use controlled
breathing techniques.
Goal partially met aeb hospice
was called in allowing the client
to die with dignity.
Transportation home did not take
place because of fear the client
would not survive the ambulance
ride.
 TEACHING PLAN

Teaching Topic
Maintaining oxygen use at home.

Clients Current Understanding of Topic

Client knows it is important to maintain O2 saturation @ >92%.

Clients Learning Style

Older adult, hand out will be sent home as a reference.

Clients Readiness to Learn

Client states, I would like to go home.

Teaching Methods Used

Verbalization and written manuals are used (attached).

Content Taught (provide content outline or attach content from reliable source)
Please refer to teaching module attached_______________________________________
https://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000048.htm

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(add pages as needed)
Evaluation of Learning
Client will keep oxygen in place at all times to maintain SpO2 levels >92% at all times.

Resources:
http://www.jblearning.com/samples/0763751375/46436_CH05_000_000.pdf
Ackley and Ladwig: Nursing Diagnosis Handbook. Mosby
Readiness for enhanced knowledge
Deficient knowledge
Ineffective health maintenance
Ineffective therapeutic regimen management
Fundamentals of Nursing textbook

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