CARE PLAN Pt.Name: J.M. 95 Y.O.

/F
Dx: Dementia,COPD,CHF,GERD,Depression,Arthritis
Allergy:Sulfa antibiotics
Nursing Assesment Nursing Plan of Care/ Intervention Rational
Diagnosis Goal

SOB when resident agitated or tired Ineffective To maintain an 1.Continue to monitor respiratory rate.Keep Sa
breating effective O2 88%-93% Maintain an
Subjective:Resident states feel tired r/t breathing (To detect changes in oxygenation.) effective
and prefer stay in her room,noted COPD/CHF no SOB. breathing
nobody helps her this morning 2.Redirect Resident when escalated anxious
Started from (May new stimuli reduce anxiety& fatigue) until December
Objective: Nov. 7 to Nov. 1,2017
Anxious & restless 30, 3.Continue to monitor residents behavior
(dressed up & made bed by herself). 2017 (for early sign and symptoms of anxiety & fatigue
to prevent SOB)
Skin dry,acyonotic,no bruises or
rashes noted. 4.Maintain upright position during rest time
( maximum lung excursion and chest expansion.)
Lung & cardio auscultation: No with elevated low extremities
adventitious sounds. (to prevent edema)

Edema: low extremities, no pitting. 5. Control weight.Refer to the dietitian.

(Obesity increases the risk for atelectasis,
Nutrition: Regular diet,feed self hypoventilation, and respiratory infections)
100%
Weight:77.2kg 6.Encourage communicate with other residents/
October:75.4kg companionship
(Can help to ease anxiety, increase coping skills &
BM: formed,soft,once a day. pass time)
Continent/Independed
Help patient with ADLs, as necessary.
Decreased mobility & ROM r/t (Avoid overexertion & fatigue)
arthritis
7.Develop an individual
Subjective:1.VS: BP101/63, PR 67, exercise program.Refer to PT.
SaO2 97% T 36.7 (Exercise increase oxygen level & residents
sense of well-being)

Breathing exercises:pursed-lip breathing,

diaphragmatic breathing 2-3 times a week