Lamar State College-Port Arthur Upward Mobility Nursing Program: Care Plan

Lamar State College-Port Arthur
Upward Mobility Nursing Program:

Care Plan
Student Name: EVELYN UCHENDU Date: January 25, 2011 Instructor:
4 <4-3 <3-0 Points Earned
Appropriate medical terms and/or 1 - 2 inappropriate medical term and/or >2 Inappropriate medical term and/or
abbreviations used throughout abbreviation used abbreviation used
Correct spelling and grammar used 1-2 errors in spelling and/or grammar >2 errors in spelling and/or grammar
throughout
Highest Priority (according to student) Highest Priority (according to student) NANDA Developed NANDA not the highest priority
NANDA fully developed development incomplete without preapproval
Source is documented correctly using APA Source is not indicated or APA format is
format incorrectly used
12 <12-6 <6-0 Points Earned
Minimum of 3 appropriate NANDA problems 1-2 errors in: Minimum of 3 appropriate NANDA >2 errors in: Minimum of 3 appropriate
identified, properly written, and properly problems identified, properly written, and NANDA problems identified, properly written,
prioritized properly prioritized and properly prioritized
Subjective & objective data included that are Either subjective or objective data is missing on Subjective or objective data is missing on care
defining characteristics of nursing diagnosis care plan or data is not a defining characteristic plan and data is not a defining characteristic
of developed nursing diagnosis of developed nursing diagnosis
Well written Goals which include: Appropriate Goals include all but one of criteria: appropriate Goals missing >1 of criteria: appropriate short
short term and long term goals; outcomes short term and long term goals; specific, realistic term and long term goals; specific, realistic &
that are: specific, realistic & measurable, a & measurable, a definite time frame for measurable, a definite time frame for
definite time frame for achievement, and achievement, and consideration of patient’s achievement, and consideration of patient’s
consideration of patient’s desires & desires & resources desires & resources
resources
Interventions: relate to the goals; are specific Interventions include all but one of criteria: relate Interventions missing >1 of criteria: relate to
and clearly stated to include: Who performs, to the goals; are specific and clearly stated to the goals; are specific and clearly stated to
how, when, where, time/frequency, & include: Who performs, how, when, where, include: Who performs, how, when, where,
amount time/frequency, & amount time/frequency, & amount
2010 Lamar State College – Port Arthur Page 1 of 5

Care Plan
Interventions are correctly identified as (I) 1 - 2 interventions are not identified as (I) >2 interventions are not identified as (I)
Independent or (C) collaborative Independent or (C) collaborative or one Independent or (C) collaborative or >1
intervention is incorrectly labeled interventions are incorrectly labeled
Rationale indentified for each intervention and 1 - 2 rationales are not indentified for each >2 rationales are not indentified for each
includes source and correct page number intervention or incorrect source and page intervention or incorrect source and page
number given number given
Appropriate evaluations are included for short Inappropriate or incomplete evaluations for 1-2 Inappropriate or incomplete evaluations for
term and long term goals short term or long term goals are present >2 short term or long term goals are present
Late Penalty: Comments: Total Points Earned (maximum of 100)
Late assignments will be penalized 10

Late Points Deduction
points for every day late after the date and
time due – No exceptions
Final Score

Care Plan
PROBLEM LIST
List and Prioritiz a minimum of 3 problems.

Type your answer in the space provided. The cells will expand as you type.
Priority # Nursing Diagnosis R/T Etiology AEB Subjective/Objective Data
1 Impaired gas exchange R/t ventilation perfusion imbalance AEB low O2 saturation of
85%, increased respiratory rate of 26, excessive secretions.
2 Ineffective breathing pattern R/T anxiety, AEB patient stating “Am so scared to
breathe, It hurts to breathe, respiratory rate of 26 beats per minute, excessive
secretion.
3 Activity intolerance R/T fatigue, energy shift to meet muscle needs for breathing to
over airway obstruction AEB patient stating “it’s so hard to breath”, weak muscle
endurance, inability to perform ADL.
4 Altered perception R/T neurological disturbance AEB patient stating “there is poison in
the IV”.
5 Ineffective Self Health Management R/T mental status AEB Patient stating “There is
poison in the IV”, medical diagnosis of “Schizophrenia” noncompliance therapeutic
intervention.

Care Plan
INTERVENTION
DIAGNOSIS BY NANDA PLAN/GOAL RATIONALE (Page #) EVALUATION
(Indicate I or C)
SHORT TERM: 1. Nurse will administer 1. When the respiratory 1. Short-term goal #1 met
NANDA #1: prescribed oxygen on 2 exceeds 30 beats per 95% on 1/25/2011 at 0900
Patient will:
liters flow by nasal cannula. minute along with other AEB O2 saturation 95-96%
Will monitor respiratory physiological measures, a room air, and heart rate 16
1. Impaired Gas Exchange 1. Patient will demonstrate
rate, depth, and ease of significant respiratory or beats per minute.
R/T Altered oxygen supply, improved ventilation and
respiration. Watch for use cardiovascular alteration
obstruction of airways by adequate oxygenation as
of accessory muscles and exits, and O2 saturation of
secretions, evidenced by oxygen
nasal flaring, monitor skin less than 90% indicates
bronchospasms. saturation of 95% - 100%
and mucous membrane significant oxygenation
on room air, and decreased
color, monitor vitals and problems. (p.402 & 403)
respiratory rate between
pulse oximetry for O2
14-16 beats per minutes by
saturation every 2 hours,
the end of second day of
encourage adequate rest
admission.
and limit activities to within
patient’s tolerance.(I)
2. Patient will maintain 2. Nurse will auscultate 2. The presence of 2. Short - term goal #2 met
clear lung fields and free of breath sounds noting wheezes will alert to airway 100% on 1/27/2011 1200
signs of respiratory distress adventitious breath sounds obstruction, which will AEB lung sounds clear on
AEB no presence of like wheezes every 2 exacerbate existing auscultation, secretion
AEB wheezes, hours; will assist patient hypoxia; Controlled within normal range - small
decreased(moderate) with measures to improve coughing uses the thin and clear.
Subjective Data:
secretions, and adequate effectiveness of cough diaphragmatic muscles,
O2 saturation of 90% or effort, such as having the which makes the cough
higher by discharge patient inhale deeply, hold more forceful and effective,
the breath for several and an upright position
seconds, and cough two or allows for maximal lung
three times with mouth expansion; lying flat causes
“Am scared to breathe” 3. Patient will return
open while tightening the abdominal organs to shift
and “ It’s so hard to demonstration and
upper abdominal muscle as toward the, which crowds
breathe” verbalize understanding of
tolerated, will position the lungs and makes it
therapeutic interventions by
patient in semi-fowler’s more difficult to breathe
discharge.

Care Plan
position, in an upright (p.129 ).

posture at 45 degrees and
reposition every 2 hours.
(I) $ (c)
LONG TERM: 3. Will teach the patient 3. The use of MDI will 3. Short – term goal #3 met
Objective Data: how to correctly (100%) ensure the correct dose of 100% on 1/27/11 at 1000
use MDI while medication administration. AEB patient demonstrated
administering medication correctly (100%) on the use
O2 saturation of 85% on 2 1. Patient will implement
every 4 hours. (I) of MDI, and verbalized
liter oxygen flow, heart rate life style changes to remain
understanding th of the
of 26 beats per minute, free of Asthma attacks for 6
importance of asthma
presence of wheezes on months after discharge
medications.
auscultation, flushed skin, AEB no more
and labored breathing. exacerbations of Asthma
4. Nurse will collaborate 4. May family needs to get 4. Long – term goal not met
by the end of 6 months
with family to reinforce the more involved in assuring as of 1/27/11 at 1200. More
period.
need for the patient to take that the patient takes her time needs to elapse in
all her medications medication correctly as order to evaluate long-term
correctly as prescribed prescribed. goal.
prior to discharge. (C)
SOURCES (APA Format): Reference:

Ackley, B.J., Ladwig, G.B. (2009). Nursing Diagnosis Handbook . An Evidence-Based Guide to Planning Care. ( 9th ed ) . Mosby Elsevier
Reviewed & Revised 1/12/2010

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Lamar State College-Port Arthur

Upward Mobility Nursing Program:

Student Name: EVELYN UCHENDU Date: January 25, 2011 Instructor:

4 <4-3 <3-0 Points Earned

12 <12-6 <6-0 Points Earned

2010 Lamar State College – Port Arthur Page 1 of 5

Late Penalty: Comments: Total Points Earned (maximum of 100)

Late assignments will be penalized 10

2010 Lamar State College – Port Arthur Page 2 of 5

List and Prioritiz a minimum of 3 problems.

Priority # Nursing Diagnosis R/T Etiology AEB Subjective/Objective Data

2010 Lamar State College – Port Arthur Page 3 of 5

2010 Lamar State College – Port Arthur Page 4 of 5

position, in an upright (p.129 ).

SOURCES (APA Format): Reference:

Reviewed & Revised 1/12/2010

2010 Lamar State College – Port Arthur Page 5 of 5

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