NURSING CARE PLAN Clients initials S.E.

Age 5
Nursing System Educative Supportive


ASSESSMENT NURSING DIAGNOSIS PLANNING IMPLEMENTATON EVALUATION

DATA COLLECTION

SCD
COLLABORATIVE PROBLEM

GOAL/OBJECTIVES

NURSING ORDERS

RATIONAL FOR
NURSING ORDERS

METHODS OF NRSG
ASSISTANCE

GOAL MET, NOT
MET, PARTIALLY
MET
SUBJECTIVE DATA
Dx. Asthma
History unsteady gait and
hallucinations
Clients states she does not
have to go to the bathroom.
Also stated last bowel
movement was 3 days ago

OBJECTIVE DATA
BP 105/60, Temp 36.8 C,
RR 22, HR 98, O2 94,
blood sugar level 89,
weight 34.4kg, height 125
Patient appears to be the
stated age
Oriented to selI, place, and
time
Cardio: regular rate and
rhythm without murmur.
Lungs: wheezing
Skin is intact.
Abdomen is distended,
bowel sounds present in all
4 quadrants

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PRIORITY #2 Alteration in
bowel elimination:
constipation related to
immobility secondary to
unsteady gait as evidence by
defecation occurring less
than 3 times per week

RATIONALE PRIORITY #2
According to Maslow`s
Hierarchy oI Needs excretion
oI bodily Iluids is a
physiological need that must
be met

GOAL:
1. Patient will have a
bowel movement
within 24 hours
2. Patient will
verbalize an
understanding of
methods of
preventing
constipation within
24 hours

OB1ECTIVES:
1. Client will increase
intake of food high in
fiber
2.Client will do
activities of daily
living and exercise as
able
3. Client will increase
her intake of fluids
1.1 Encourage
consumption oI whole
grains
1.2 Encourage
consumption oI Iruits
high in Iiber
1.3 Limit intake oI
carbohydrates (without
Iiber)
2.1 Encourage client to
perIorm ADLs
2.2 Assist client in
ambulating
2.3Demonstrate in bed
exercises
3.1 Encourage Iluid
intake oI 1500 ml/day
3.2 Limit intake oI
carbonated beverages
and citric Iluids
3.3 implement
psychosocial Iactors to
help stimulate
micturation

1. A Iunction oI the
nurse is to assist
clients with diet and
bowel preparation
(Kozier & Erb, 2008)

2. Nursing strategies
include administering
cathartics and
antidirrheals;
administering
cleansing,
carminative, or
retention enemas;
applying protective
skin agents;
monitoring Iluid and
electrolyte imbalance;
and instructing clients
in ways to promote
normal deIecation.
(Kozier & Erb, 2008)
Monitored patients
Iluid input and output.
Encouraged an increase
in daily Iluid intake.
Placed the client in low
Ilower`s position.
Provided ice water.
Encouraged the patient
to change positions
while in bed and sit in a
chair to eat breakIast
and lunch. Encourage
patient to comb hair,
brush teeth, and wash
Iace upon waking up.
Demonstrated range oI
motion exercises the
patient could do while
in bed.
1. Goal not met
as evidence by
patient not
having a bowel
movement and
did not verbalize
ways to prevent
constipation.
Patient needs
more time to
Iully achieve
goals. Nursing
care should be
continued until
goals are met.

NORFOLK STATE UNIVERSITY Student Tessa Wilson
DEPARTMENT OF NURSING Date 10/15/2011

NURSING CARE PLAN Clients initials S.E. Age 5
Nursing System Educative Supportive

ASSESSMENT NURSING DIAGNOSIS PLANNING IMPLEMENTATON EVALUATION

DATA COLLECTION

SCD
COLLABORATIVE PROBLEM

GOAL/OBJECTIVES

NURSING ORDERS

RATIONAL FOR
NURSING ORDERS

METHODS OF NRSG
ASSISTANCE

GOAL MET, NOT
MET, PARTIALLY
MET

SUBJECTIVE DATA
Dx. Asthma
History unsteady gait and
hallucinations
Sister reported patient
exhibited 'hallucinations
in the middle oI the night.
Patient reports being tired

OBJECTIVE DATA
BP 105/60, Temp 36.8 C,
RR 22, HR 98, O2 94,
blood sugar level 89,
weight 34.4kg, height 125
Patient appears to be the
stated age. Skin is intact.
Oriented to selI, place, and
time. Cardio: regular rate
and rhythm without
murmur. Lungs: wheezing,
normal depth, parallel chest
expansion, patient breaths
through mouth.

PRIORITY #1 At risk for
ineffective breathing pattern
due to inflammation
secondary to asthma as
evidence by fatigue and
labored breathing

RATIONALE PRIORITY #1
According to Maslow`s
Hierarchy oI Needs breathing
is a physiological need that is
required Ior survival

GOAL:
1. Client will verbalize
an increase in comfort
from labored breathing
in 1 hour
2. Client will verbalize
ways to help achieve an
adequate breathing
pattern within 24 hours

OB1ECTIVES:
1. Client`s breathing
pattern will be
maintained as evidence
by eupnea in 1 hour
2.Client will understand
and verbalize factors
that will worsen
patients pulmonary
condition
3. Client will have an
absence of cyanosis
1.1 encourage Iluid intake
oI 1,500 ml/ day
1.2 Teach patient how to
count own respirations and
relate respiratory rate to
activity tolerance
1.3Explain to the patient the
signs oI respiratory
compromise
2.1 Provided therapeutic
environment
2.2 Discuss possible
precipitating Iactors which
may worsen condition
2.3 Discussed
environmental Iactors (e.g.
pollen) that may worsen
patients condition
3.1 Encouraged deep
breathing
3.2 Follow prescribed
pharmacological regimen
3.3 Prevent patient Irom
taking out her nasal cannula
1. Nursing
interventions to
promote oxygenation
include promoting
healthy breathing and
a healthy heart, deep
breathing and
coughing, and
hydration. (Kozier &
Erb, 2008)

2. The nurse teaches
the client about home
care activities to
maintain a patient
airway and gas
exchange and to
promote healthy
breathing. (Kozier &
Erb, 2008)

Encouraged an increase
in daily Iluid intake.
Monitored patient`s
vital signs.
Demonstrated deep
breathing exercises.
Placed patient in high
Iowlers position.
Monitored patient`s
level oI consciousness.
Administered
medication as
prescribed. Monitor
respiratory rate, depth
and eIIort. Monitor
client`s behavior and
mental status Ior the
onset oI restlessness.
Remind the client to
breathe through her
nose and not her mouth

1. Goal not met
as evidence by
presence oI
labored breathing
and inability to
achieve comIort.
Patient needs
more time to
Iully achieve
goals. Nursing
care should be
continued until
goals are met.