Redlands Community College - School of Nursing Care Plan

Skin Integrity and Hygiene Dry, scaly skin pale skin color thick and discolored fingernails scabbed over wound on forehead abrasions on forehead edema on left foot ted hose on left foot Temperature Maintenance hands cool to touch afebrile Abnormal Assessment Data Oxygen - Respiratory non productive cough barrel shaped chest wheezes in upper bilat lobes 3 liters O2 O2 sat of 80% shallow breathing Hx of COPD Placed on BIPAP overnight Oxygen - Cardiovascular Hx of coronary heart disease wheezes in upper bilat lobes afilbrullation O2 sat of 80%

Rest, Sleep, and Relief from Pain verbalizes pain/discomfort facial expression: Grimace pain located in rt leg/ankle leg guarding PIL: 8/10 use of BIPAP overnight

Nutrition Heart Healthy Diet

Fluid and Electrolytes hemoglobin level under 8 rcv'd 2 units of blood rcv'd 1 unit of plasma Edema in left foot

Elimination - Gastrointestinal Use of bed pads

Neurological Function decreased visual acuity Orientated unless on pain meds decreased hearing acuity

Personal Safety Rt ankle splint decreased mobility status smoker no siderails On pain meds

Environmental Safety O2 tank present

Infection Control None

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Redlands Community College - School of Nursing Care Plan

Sexuality Married Chronic health problems Coronary Artery Disease Sensory Stimulation Wears glasses decreased hearing acuity/no aids TV used constantly unfamiliar surrounding Belongingness Head of household Coping Asks for pain medication

No constant family present

Other psychosocial data Smoker watches tv impact on activity level loves his 2 dogs

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Redlands Community College - School of Nursing Care Plan

Nursing Diagnosis #1 RT AEB Goal patient will demonstrate improved symptoms of respiratory distress prior to sxy scheduled at 8am on 10/13/12 Interventions maintain adequate I&O for mobilization of secretions elevate head of bed to at least 30 encourage deep breathing exercises and frequent position changes provide psychological support by listening actively to questions and concerns Nursing Diagnosis #2 RT AEB Rationale to reduce viscosity of respiratory secretions to maintain airway clearance to promote optimal chest expansion and drainage of secretions to reduce anxiety Ineffective breathing pattern narcotic administration O2 Sats of 80%, shallow breathing, increased sedation Evaluation

patient looks more calm and advised that he can breathe eas Evaluation Reduce crackles in bilateral lobe Patient presents with decreased difficulty breathing Patient maintains O2sats of 85% or higher Patient exhibits a more calm and restful state

Acute Pain movement of bone fragments, edema and injury to soft tissue related to trauma reports of pain, self-focusing/narrowed focus, facial mask of pain Goal Evaluation patient will verbalize relief of pain before end of shift (Current PIL 8/10, goal is 4/10) Goal was met, pain rated at 3/10 by end of shift Interventions Evaluation Rationale Relieves pain and prevents bone Maintain immobilization of right ankle by means of bedrest and splint Patient verbalized relief of pain displacement/extension of tissue injury Elevate and support right ankle Medicate with pain medication prior to care activities Apply ice pack to right ankle Promotes venous return, decreases edema, and may reduce pain Promotes muscle relaxation and enhances participation Reduces edema and hematoma formation, decreased pain sensation

Patient displays relaxed manner; sleeps and relaxes appropria

Patients was more willing to complete bath once pain medication taken effect

Unknown if goal was met: Patient remained in splint throughout however, patient did advise that pain in ankle was not as inte

Source:

Doenges, M.E., Moorhouse,M.F., & Murr, A.C. (2009-2011) Nursing Care Plans Guidelines for Individualizing Client Care Across the Life Span (8th ed). F.A. Da

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Redlands Community College - School of Nursing Care Plan

Abnormal Assessment Data Activity On ordered bed rest due to fx right ankle

Elimination - Urinary Decreased output dark yellow urine usage of Foley catheter

Self-concept and Self-esteem reduced energy levels disorganized thinking while on pain medication

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Redlands Community College - School of Nursing Care Plan

Spiritual and Cultural Wife prayed for patient bible on bedstand

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Redlands Community College - School of Nursing Care Plan

Ineffective breathing pattern narcotic administration O2 Sats of 80%, shallow breathing, increased sedation Evaluation patient looks more calm and advised that he can breathe easier Evaluation Reduce crackles in bilateral lobe Patient presents with decreased difficulty breathing Patient maintains O2sats of 85% or higher Patient exhibits a more calm and restful state Acute Pain movement of bone fragments, edema and injury to soft tissue related to trauma reports of pain, self-focusing/narrowed focus, facial mask of pain Evaluation Goal was met, pain rated at 3/10 by end of shift Evaluation Patient verbalized relief of pain

Patient displays relaxed manner; sleeps and relaxes appropriately Patients was more willing to complete bath once pain medications had taken effect Unknown if goal was met: Patient remained in splint throughout shift; however, patient did advise that pain in ankle was not as intense

& Murr, A.C. (2009-2011) Nursing Care Plans Guidelines for Individualizing Client Care Across the Life Span (8th ed). F.A. Davis Co.

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Redlands Community College Nursing Program Assessment Based on Human Needs Framework

Prioritize your client's top categories. Identify why you chose to prioritize the needs in the order you have chosen Human Needs Framework Category 1 Oxygen-Respiratory Rationale Non-productive cough, bilateral diminished lung sounds, wheezing in lungs bilaterally, barrell shaped chest, pt is on constant oxygen, hx of COPD, O2 sat of 80%, shallow breathing, use of BIPAP machine Verbalization of pain, grimacing, pain located in right anke due to fx, PIL: 8/10, Use of BIPAP machine Afibrllation, O2 sat of 80%, Hx of CAD Edema in left foot, 2 units of blood and 1 unit of plasma administered; hemoglobin less than 8

2 3 4

Pain Cardiovascular Fluid and Electrolytes