Example Nursing Diagnosis and Careplan for N205 Mini careplansPotential for Injury (Apsiration) Assessment Data Related

toNursing DiagnosisN u r s i n g D i a g n o s i s G o a l N u r s i n g I n t e r v e n t i o n s E v a l u a t i o n What Objective and SubjectiveData lead you to this one diagnosis. Objective: CVA with Left Sided ParalysisDiminished Gag ReflexDifficulty Swallowing Liquids Subjective (from patient or family)" Mom chokes every time sheeats". Potential for Injury (Aspiration) related to dimminshed gag reflexand impaired swallowing ability Goal (Should be broad statements whichsolve the Problem part of the NursingDiagnosis Statement. )Patient will not have injury related toaspiration (10/20/95 2-10pm) Outcome Criteria Specific and observable things whichallow an observer to determine if the patient met the goal1 . P a t i e n t wi l l h a v e n o c h o k i n g episodes while eating. 2. Patient color will remain cyanotic3 . P a t i e n t l u n g s o u n d s w i l l r e ma i n clear 4 . P a t i e n t C XR wi l l s h o w n o s i g n s o f aspirationInterventions should be things thatyou do (either independently or dependently) to assist the patient inreaching the goal. They should befocused on addressing the cause of the problem (the related to part of the nursing diagnosis statement) Place patient on side or with HOB toavoid aspiration of mucous.Feed patient liquids which have beenthickened, as thin liquids are morelikely to cause aspiration.Monitor lung sounds for signs of aspirationMonitor Lab and X-ray data for signs of aspiration.Evaluate based on the patients progresstowards each of theoutcome Criteria1 . P a t i e n t d i d n o t have problemswith chokingduring my shift.2 . P a t i e n t c o l o r w a s pink.3 . P a t i e n t l u n g sounds remainedclear.4 . Y o u m a y o r m a y not have lab/X-raydata to report,depending on theday and what testshave beenordered.Goal Met, ContinuePlan. ALSO INCLUDE

Was this an appropriateNursing Dx for THISPATIENT? It may turnout that after you carefor the patient, youdiscover a higherpriority nursingdiagnosis.

Sample Nursing Careplan for N205 : Fluid Volume Excess Assessment DataNursing DiagnosisGoal: Patient will not havefluid volume excessI n t e r v e n t i o n s E v a l u a t i o n (List the things your patienthas which make you suspecthe/she is overhydrated)Objective:Weight gain in past monthEdemaTight, shinny skinCrackles in lungsDecreased urine output Na level 134Hct level below 35Subjective:"My feet and legs are soswollen""I just can't breath if I'm flatin bed"Fluid volume excess RT water retentionsecondary to decreased renal perfusionand cardiac output Outcome Criteria: 1 . C l i e n t ' s w e i g h t w i l l b e WNL for Ideal BodyWeight (give numbers).2 . C l i e n t w i l l v e r b a l i z e ability to breathecomfortably.3 . L u n g s

will be clear 4.Vital Signs will Be WNL5.Relevant l a b v a l u e s (Sodium, Hct) will beWNL ( Na 135-145) etc.6 . U r i n e w i l l b e c l e a r yellow with output>30cc/hr 7 .I n t a k e wi l l n o t b e g r e a t e r than output8 . N o e v i d e n c e o f s k i n breakdown.Restrict fluids to 350 cc per shift.SR: Excessive fluids will worsen client'scondition. (Sparks, 110)Weigh client at same time each day, using samescale. SR: Provides baseline and continuingdatabase for monitoring changes and evaluatinginterventions.(Brunner, 1039)Administer diuretics (Lasix) as prescribed. SR:To increase excretion of water. (Ulrich, 508)Help client into a position that aids breathing,such as Fowler's or Semi-Fowler's.SR: To increase chest expansion and improveventilation. (Sparks, 110)Encourage client to cough and deep breathe q2h.SR: To prevent pulmonary complications.(Sparks, 110)Asculatate Lung Sounds q 4 hours. Monitor PulseOx Q 4 hours, Monitor CXR results, as performed.SR: To look for pulmonary vascular congestion, pleural peffusion, or pleural edema. (Ulrich, 508)Assess vital signs q4h.Assess lab values q shift.Monitor extremities for venous return (check pulses and capillary refill) q shift.SR: Decrease in venous blood flow results in anincrease in venous pressure, a rise in capillaryhydrostatic pressure, a net filtration of fluid outof the capillaries, and thus edema. (Brunner,625)Administer vasodilators, as ordered. SR: Toimprove renal blood flow. (Reduced renal1 . C l i e n t s w e i g h t was stable at 145lbs.2 . C l i e n t s t a t e d s h e could breathe better 3 . L u n g s h a d decreasedcrackles4 . V i t a l s i g n s w e r e T 98.6 P 87 R 24B/P 134/865 . N a w a s 1 3 5 6 . H c t w a s 3 6 7 . U r i n e w a s c l e a r yellow withoutput over 30cc/hr 8 . I n t a k e w a s 3 5 0 c c this shift withoutput of 475 = Negative fluid balance of 125 ccthis shift.9 . T h e r e w a s n o s k i n breakdown

perfusion stimulates the renin-angiotensin-aldosterone mechanism) (Ulrich, 508)Encourage client to restrict Na intake.SR: Restriction of NA intake reduces theamount of Na that passes through the kidney and is reabsorbed. Thisresults in decreased retention of water. (Ulrich,37)Test urine specific gravity q8h.SR: High specific gravity indicates fluidretention. Fluid overload may alter electrolytevalues. (Sparks, 110)Examine skin q8h for signs of bruising or other discoloration.SR: Edema may cause decreased tissue perfusionwith skin changes. (Sparks, 108)Skin care q4h. (Cleanse wound with saline, dry,apply polysporin and dry gauze dressing.)SR: To prevent further skin breakdown. (Sparks,108)Reposition client q2h. References

Brunner, L.S. & Suddarth, D.S. (1988). Medicalsurgical nursing. Philadelphia: Lippincott.Sparks, S.M. (1993). Nursing diagnosis reference manual (2nd ed.). Springhouse, PA: Springhouse Corporation.Ulrich, S.P., Canale, S.W., & Wendell, S.A. (1994). Medical- surgical nursing care planning guides (3rd ed.). Philadelphia:Saunders.