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Plan of Care Sheets


Assessment
NANDA 3 part
6 items
Nursing
Subjective
Diagnosis related
&/or
to As Evidence by
Objective
Designate with
STG
S or O
LTG
1. O
When I get up from
bed I fell lightheaded

2. S
I feel I do not have
the strength to go
thru the day

NANDA 3 part
nursing
diagnosis:
Activity intolerance r/t
imbalance between oxygen
supply and demand AEB
exertional dyspnea and
verbal report of weakness.

Evaluation
Correlate with
interventions
Number them!

1.

2.

2.

3.

3.

4.

4.

When an adult rises to the standing


position, blood pools in the lower
extremities and symptoms of CNS
hypoperfusion may occur.

2. Adjust clients daily


activities and reduce
intensity of level.
To prevent strain and overexertion.

To conserve energy and promote


safety.

4. Make sure call light is


within patient reach.
To identify necessity of assistive
devices.

STG: Clients O2
saturation will remain
higher than 90%
throughout the shift.

5. S
I have shortness of
breath during
therapy

6. O
SPO2= 86%

Interventions
(actually
performed)
Correlates with
plan
Put here what was
done
Number them!
1.

3. Teach the patient the


importance of conserving
energy.

3. S
I feel weak all the
time
4. S
I do not think can
walk alone to the
restroom

Plan (Intervention
with brief rationale)
for each one
9 individual plans
(3) Assessment
(3) activity
(3) action
Number them!
1. Assess BP when the
patient gets up from bed.

5. Teach and assist in use


conscious controlled
breathing techniques
during PT.
Inspiratory muscle training is
effective in increasing endurance
of the client and decreasing
dyspnea

6. Use pulse oximetry to


monitor O2 saturation.
Pulse oximetry is a useful tool to
detect changes in oxygenation.
O2 saturation should be maintained
at 90% or greater

LTG: By
discharge the
client will report
minimal discomfort in
breathing efforts.

7. Reposition the patient


q2h.

5.
5.

6.

Repositioning promotes comfort


and promotes circulation.

8. Recommend the client to


performs ROM exercises
for at least 5 min daily.
ROM.
Range-of-motion exercises are
intended to help maintain
muscle tone and flexibility.

6.

7.
7.

8.

8.

9. Encourage the patient to


perform deep breathing
exercises.
Deep breathing exercises helps
to promote feelings of calm and
relaxation.

9.
9.