Nursing Care Plan
Patient
E.K.
Assessment
Objective:
2L NC
O2 Sat 92%
All lobes diminished
Crackles in R mid
&lower lobes
Area
Med-Surg
Nursing Diagnosis
Planning/Outcomes
Student
Audrey Hadad
Interventions
Nursing Diagnosis
#1
Short Term Goal:
Impaired gas exchange
r/t increased airway
resistance AEB by
crackles & rhonchi and
patient’s complaint od
SOB.
Patient will maintain
oxygen saturation
above 90% by end
2. position in high
of shift.
1. Helps evaluate the
respiratory rate and depth.
degree of respiratory
distress (Gulanick pg
436)
3. Encourage expectation
Long Term Goal:
Pt complains of SOB for
the past 3 days
Pt will verbalize that he
is free from SOB and
have clear breath sounds
by discharge
Rationale
1. Assess and record
fowler’s (or at least semifowler’s)
Subjective:
Clinical Day
March 17, 20xx
of sputum; and suction if
indicated.
4. Administer O2 as
prescribed
5. Monitor Pulse Ox
2. sitting position
promotes lung
excursion & chest
expansion (Gulanick
pg 36)
3. Thick secretions
with ineffective
expectation can cause
impaired gas exchange
especially in small
airways. Suctioning
may need to be initiated
if pt is unable to
expectorate secretions.
(Gulanick pg. 436)
4. for management of
underlying resp. distress
or pulmonary condition
(Doenges pg 169)
Evaluation
Short Term Goal:
Met
Pt maintained an O2 Sat
> 90% when checked
Q2hrs during shift and
was 92% at end of shift
Long Term Goal:
Unmet
Crackles were still
heard on auscultation of
patient’s lungs at end of
shift, although pt states
that he “feels like it’s
easier to breath”
5. to verifiy
maintenance of O2 sats
(Doenges pg 169)
1
Nursing Care Plan
Assessment
Objective:
Pt has ineffective cough,
diminished breath
sounds in both lungs and
crackles and rhonchi are
auscultated in Rt lung
Subjective:
Pt states that he
“coughs and nothing
comes out”
Audrey Hadad
Nursing Diagnosis
Planning/Outcomes
Nursing Diagnosis
#2
Short Term Goal:
Ineffective airway
clearance r/t immobilized
secretions AEB crackles
and rhonchi in lungs
Patient will
demonstrate
effective cough and
expectorate sputum
by end of shift
Interventions
Rationale
1. Auscultate patient’s
1. to evaluate/establish
chest
baseline of
characteristics of and
presence of breath
sound (Doenges pg
168)
2. fluids prevents
dehydration and help
keep secretions thin
(Gulanick pg 436)
2. Encourage intake of
fluid
3. Encourage activity and
3 Activity helps
position changes q2hrs
mobilize secretions and
prevent pooling in lungs
(Gulanick pg 436)
Long Term Goal:
Patient will maintain
a patent airway and
4. Encourage pt to cough
out secretions / sputum
have clear breath
sounds by discharge
5. Teach controlled cough
techniques ie Huff
Evaluation
Short Term Goal:
Met
Client demonstrates
controlled cough – huff
and acknowledges an
understanding of the
rationale, he also began
to cough up small
amounts of sputum
Long Term Goal:
Unmet
4. Coughing is the most Crackles were still heard
helpful way to clear
secretions (Gulanick pg
436)
5. Forced expiration
coughing may be
effective to move
trapped mucus into
larger airways for pt to
couch up (Gulanick pg
436)
on auscultation of
patient’s lungs at end of
shift
2
Nursing Care Plan
Assessment
Objective:
Age 78
Has weak gait
Has DM
IV peripheral line
Acute illness
(pneumonia )
Audrey Hadad
Nursing Diagnosis
Nursing Diagnosis
#3
Risk for Falls r/t
presence of an acute
illness AEB client’s
statement of lightheadedness
Planning/Outcomes
Short Term Goal:
Interventions
1.Evaluate degree of risk
1. standard fall risk
for falls on admission
assessment tool can
determine level of risk
(Gulanick pg65)
Patient will be free
from injury- falls
during this shift
2. Review med regimen
2. Certain meds (anti –
and how it can effect
client
locked position and raise
upper half of side rails
hypertensives) can
contribute to weakness
& gait/balance
disturbances (Doenges
pg 365-366)
3. These have been by
research to reduce falls
(Gulanick pg66)
4. Encourage and teach Pt
4. Non-skid footwear
to wear non-skid socks
while in the hospital and at
home non-skid
socks/slippers/shoes
5. Place personal items
with-in close reach
including call light
provides sure footing
(Gulanick pg66)
3. Place bed in low,
Subjective:
Stated that he was
feeling light-headed
when he was SOB
Long Term Goal:
Pt will verbalizes
behaviors to protect
self from injury –
falls before
discharge
Rationale
6. Instruct Pt to use call
light to request assistance
before getting out of bed
5. Stretching for items
can disturb Pt’s balance
and contribute to falls
(Gulanick pg66)
Evaluation
Short Term Goal:
Met
No falls during this
shift
Long Term Goal:
Met
Patient states that he
will wear hir nonskid socks while in
the hospital and use
his call light to get
assistance before
getting out of bed
6. Assistance in
ambulation reduces risk
for falls (Doenges pg
366)
3
Nursing Care Plan
Audrey Hadad
References
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2013). Nurse's pocket guide: diagnoses, prioritized interventions, and
rationales (13th ed.). Philadelphia: F.A. Davis.
Gulanick, M., & Myers, J. L. (2014). Nursing care plans: Diagnoses, interventions, and outcomes (8th ed.). Philadelphia: Elsevier
Mosby
Vallerand, A. H., Sanoski, C. A., & Deglin, J. H. (2015). Davis's drug guide for nurses (14th ed.). Philadelphia: F.A. Davis Company
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