NUR 171

Supportive Educative Nursing

Comprehensive Nursing Care Plan

James Johnston
Name

4/2-3/15
Date

6.26.2012

Priority Nursing Diagnosis List

Problem

Impaired gas exchange

Etiology

R/T hypoxic respiratory failure, acute pulmonary edema

Signs & Symptoms

AEB: patient hypoxia, O2 use.

Problem

Decreased cardiac output

Etiology

r/t A-fib

Signs & Symptoms

AEB: patient Hx, telemetry, pulmonary edema

Problem

Ineffective health maintenance

Etiology

r/t inability to make appropriate judgments

Signs & Symptoms

AEB: refusal of PT, sporadic cooperation

Problem
Etiology
Signs & Symptoms
Problem
Etiology
Signs & Symptoms
Problem
Etiology
Signs & Symptoms
Problem
Etiology
Signs & Symptoms
6.26.2012

Priority #1 Nursing Care Plan

Nursing
Diagnosis

Expected
Outcomes

Nursing Interventions
1. Assess: Assess rate,
depth, and ease of
respiration

Rationale
Evidence-based?
1. Rationale: RR 0f 30

Evaluation of
Interventions

P: Impaired gas
exchange

Client will: be
weaned from O2
per R/Tx. by
4/10/15

E: r/t hypoxic
respiratory
failure, acute
pulmonary
edema
S: AEB: patient
hypoxia, O2 use

Evaluation of
expected
outcomes

2. Intervene: Treat by
administering O2 prn per
physicians order.

Rationale: O2 should improve

hypoxia to 88-92% saturation.
(Ackley, Ladwig pg 376.)

Goal met AEB: the SN

administering O2 prn
per physicians order.

Goal met: AEB

Patient off O2,
following
therapeutic
diuresis, clear
lung fields r/t
auscultation on
4/10/15.

3. Teaching: Teach the client

purse-lip breathing

Rationale: purse-lip breathing

improves resp. function
(Ackley, Ladwig pg 377)

Goal met AEB: SN did

teach the client purselip breathing.

4. Discharge Planning: teach

client to avoid smoke/smoking

Rationale: smoke/smoking is
detrimental to resp.
health/function (Ackley, Ladwig
pg 377)

Goal met AEB: SN did

reinforce the
importance of avoiding
smoke/smoking.

indicates severe
card./resp. alteration
(Ackley, Ladwig pg.
375.)

Goal met AEB: the SN

assessed rate, depth,
and ease of respiration
q shift

Priority #2 Nursing Care Plan

Nursing
Diagnosis
P: Decreased
6.26.2012

Expected
Outcomes
Client will:

Nursing Interventions
1. Assess: BP, HR, and
3

Rationale
Evidence-based?
Rationale: it is important for

Evaluation of
Interventions
Goal Met AEB: SN

cardiac output

maintain normal
rate and rhythm
w/out dyspnea
by 4/10/15.

condition before administering

cardiac meds, w/holding if
necessary

the nurse to evaluate how the

client is tolerating cardiac
meds (Ladwig, Ackley, 2014.
P181.)

E: r/t A-fib

Evaluation of
expected
outcomes

2. Intervene: administer O2
prn per physicians order

S: AEB: patient
Hx, telemetry,
pulmonary
edema

Goal met AEB:

Client had
normal rate and
rhythm w/out
dyspnea on
4/10/15.

3. Teach: Teach the client the

benefits of a low sodium diet.

Rationale: supplemental O2
inc. O2 availability to the
myocardium (Ladwig, Ackley,
2014. P180.)
Rationale: sodium retention
leading to fluid overload
causes hospital readmission
(Ladwig, Ackley, 2014. P 185.)

4. Discharge Planning: Include

significant others in client
teaching.

6.26.2012

Rationale: support from family

+ friends is positively
associated with better
medication + self-maintenance
(Ladwig, Ackley, 2014. P 181.)

assessed BP, HR, and

condition before
administering cardiac
meds, w/holding if
necessary.
Goal met AEB: SN
administered O2 prn per
physicians order.
Goal met AEB: SN
taught the client the
benefits of a low sodium
diet.
Goal not met AEB: wife
was at new job while
students were on the
unit.

TEACHING PLAN
Teaching Topic
Bladder scanner
Clients Current Understanding of Topic
Client asks each time the scanner is used why do I need my bladder scanned?

Clients Learning Style

The client prefers talking, so topic was explained to client verbally.
Clients Readiness to Learn
Client asked why do I need my bladder scanned?

Teaching Methods Used

Discussed health risks of potential urine retention and verbally covered concepts
and reasoning for use of bladder scanner in attached article.

Content Taught (provide content outline or attach content from reliable source)
Content attached http://www.nursingtimes.net/nursing-practice/clinicalzones/continence/using-bladder-ultrasound-to-detect-urinary-retention-inpatients/5001853.article (PRINT)

Evaluation of Learning
The client understood the information presented to him and displayed both
understanding and frustration by stating fine, I got it. This was stated as client threw
6.26.2012

hands in the air. However, the teaching appeared to be successful as the client did not
question future uses of the bladder scanner.
Resources:
http://www.nursingtimes.net/nursing-practice/clinical-zones/continence/usingbladder-ultrasound-to-detect-urinary-retention-in-patients/5001853.article
Ackley and Ladwig: Nursing Diagnosis Handbook.
Impaired gas exchange
Decreased cardiac output
Ineffective health maintenance
Fundamentals of Nursing textbook

6.26.2012