Georgia Baptist College of Nursing
NR210: Nursing Care Plan
#5. Bova Tues. Meet back of classroom on the right.
Nursing Diagnosis:
: Surgical recovery delayed (risk of) r/t pt’s refusal to follow postop regime AEB pt’s refusal to sit up or cough and his fear that “incision
will burst open”.
Client Goals with
Outcome Criteria
Valid
ation:
Subje
ctive
Data:
The pt will cough
and deep breath
effectively every
2 hrs in 24 hours
(I added a time
frame) AEB:

Objec
tive
Data:

Increase
in
respirator
y
excursion
.
Pt
verbalizes
decrease
in fear of
incision
bursting.
Nursing Interventions
Assess:
1. Assess resp. excursion and
incision q2hr.
2. Assess highest level of Spirometry
with one deep breath q4hr.
Add……..Assess for s/s of fear/anxiety
re: the incision site. Need to add this
to allow you to meet the outcome
criteria of the goal.
Treat:
3. Encourage pt to deep breathe 10
times every hr between 250-1000.
Don’t use the term
“encourage”…how will you
encourage him? Give specifics.
Teach:
4. Teach pt to cough and deep breathe
with pillow in place.
5. . Teach pt how to use spirometer.
6. Teach pt about incision. What
about the incision…incision
care…splinting…?
Rationales
1. Respiratory excursion
should be symmetrical
without lag (Nursing
Health Assessment, p.
341).
2., 3., 5. Pt takes and holds
deep breath for a few
seconds. Spirometry
encourages deep
breathing. (Nursing care
Plans, p. 571).
4., 6. Splinting the
incision eases the
discomfort of coughing
and taking deep breaths
(Nursing Care Plans, p.
571).
Good job!! Nice
interventions with
rationales. Be sure to use
APA format to cite your
rationales.
Evaluate
Pt coughs and
deep breathes
effectively
every 2 hrs.
Pt’s
respiratory
excursion is
greater than
2cm.
Pt verbalizes
lessened fear
regarding
incision
bursting open.