NUR240

Nursing Care Plan Forms

Requirements: 5 Complete DNPPs. Each to include the following:

1. DNPP
2. Priority List of Nsg Dx/Choose 1 and complete the Nursing Process Form
3. Nurses Note
4. Lab Interpretation Sheet
5. Med Sheet

SUFFOLK COUNTY COMMUNITY COLLEGE

SCHOOL OF NURSING

DAILY NURSING PROCESS PLAN

NUR 240
Student Name: Jennifer Altenburg
Date of Care: 11/12/16
Patient Initials: PG
Room #: 415A DOB: 1/18/1961 Gender: M Code Status: Full
Chief Complaint/Reason for Admission: SOB, Cough, COPD, PN. ARF
Weight: 202 lbs Height: 5 9
Diet: Cardiac
Isolation: N/A
Glasses/Lenses: Glasses
Hearing Aid: N/A Oriented: A&O X4 Disoriented: N/A Desired Method of Learning: Verbal Explanation
PMH/PSH: ETOH abuse, COPD, Brain CA (dx: 7/16 Astrocytoma), CAD, TBI, Angina, Seizures, Bi-lat hip replacment L side revised 2X,
Cholecystectomy
Social History/Family History: Smoker, ETOH abuse, + h/o cocaine abuse
Allergy to drugs, food, or environment: NKA
Activity: OOB Independent
Vital signs: T: 98.1 (Oral) Pulse: A: 80 R: 82 RR: 16 B/P: 111/66 Right Arm
SaO2 : 94% Pain Scale: 4 out of 10 on pain scale pt. states 4 is acceptable level
IV: 22g in LFA placed 11/11/16 at 0900
Intake: 300 mL Output: 300 mL Tubes/ Drains/Appliances: N/A
Assessment Data: Place your initials in the box if the descriptors match your client, otherwise (*) and write a nurses note.
SAFETY: Call bell within reach. Bed in low position. Environment
INTEGUMENTARY: Skin color pink. Skin warm,
clutter free. Fall precautions: YES X NO
JA dry and intact. Mucous membranes pink and moist.
JA
Restraints:___YES X NO Suicide Risk___YES X NO
No skin breakdown.
HYGIENE: __Complete ___Partial X Self
WOUND/INCISION: No redness or increased
ORAL CARE: __ Complete X Self
JA temperature in surrounding tissues. No drainage.
JA
Wound edges well approximated. Sutures/staples/steri
strips intact.
PSYCHOSOCIAL: Stress: Substance Abuse, Brain CA
MUSCULOSKELETAL: No joint swelling or
Ways of Handling Stress: Smoking, Reading, Horror Movies
tenderness. Full ROJM. No muscle weakness.
Emotional Status: Depressed, Anxious
*
Surrounding tissue without inflammation. Steady
JA
Problems Related to Illness/Condition: Depression, Anxiety
balance and gait.
NEUROLOGICAL: A & O X 3. PERRLA. Appropriate behaviors.
SKIN RISK ASSESSMENT: 2 points for each
Verbalization clear and understandable. No dysphasia. Active ROJM
*
positive answer: N/A poor physical condition, N/A
JA
all extremities. No numbness or tingling.
inactive, N/A lethargic, N/A poor nutrition, N/A
Pt has seizure disorder and is on seizure precautions
incontinent, N/A poor mobility (over 6 = risk) Risk=0
RESPIRATORY: Respirations regular and unlabored. No SOB. No
FALL RISK ASSESSMENT: 1 point for each
cough. Nailbeds and mucous membranes pink. Breath sounds clear
positive answer: N/A confused, X seizure disorder,
bilateral. No dyspnea on exertion. No night sweats. O2 therapy:
*
N/A weak, N/A sedated, N/A poor judgment, X poor
JA
specify: 2 LPM vis NC, Diminished BS with bi-lat wheezes
sight, N/A combative, N/A unsteady, N/A
CDB/IS_______ Suction: N/A
lang.barrier, N/A incontinent, N/A poor hearing (over
5 = risk) Risk=2
CARDIOVASCULAR: No chest pain. Pulse regular. No edema of
PAIN ASSESSMENT: Pain Intensity (1-10): 4
extremities. Vital Signs Stable. Extremities warm. Brisk capillary
JA Pain tolerable: X yes, __ no
JA
refill.
X alert, __sedated FLACC Score: N/A
GI: Abdomen soft, non-tender. Audible bowel sounds. Passing flatus.
INTRAVENOUS LINES: IV site is clear, without
Stools within own normal pattern and consistency.
JA redness, swelling or pain. PIV: 22g in LFA Date
JA
Tubes: N/A
Ostomy: N/A
Inserted: 11/11/16 Tubing Change. Central Line: N/A
Date Inserted, ___Tubing Change, ___Dsg Change.
GU: Empties bladder independently and without difficulty. Urine clear
ACTIVITY: OOB Independent
and yellow to amber. Catheter: N/A
JA Sleep Pattern: Midnight-8am
JA
Ostomy: N/A
NUTRITION: Diet: Cardiac
CLIENT ED/DISCHARGE PLANNING:
Appetite: X Good>75% of meal__Fair50-75%___Poor <50%
JA X Needs Identified
JA
X Self___Assist Diet Supplement: N/A
X Client Education Started

Priority Nursing Diagnosis

1. Impaired Gas Exchange R/T altered oxygen supply and alveolar-capillary membrane
changes occurring with inflammatory process and exudate in the lungs AEB positive
CXR and CT of chest showing bi-lateral infiltrates of upper and lower lobes, cough,
diminished breath sounds with wheezes upon auscultation.
- Assess for and promptly report S/S of respiratory distress
- Auscultate breath sounds at least q2h or as indicated by patient condition
- Administer antibiotics as prescribed by HCP
- Monitor ABG results
- Teach patient to maintain optimal positon (HOB elevated, change position
q2h)
2. Ineffective airway clearance R/T increased secretions associated with irritation of the
respiratory tract AEB productive cough with thick yellow secretions, positive chest x-ray
and CT scan.
- Asses for and promptly report any S/S of respiratory dysfunction/distress
- Administer anti-mucolytic as prescribed by HCP
- Inspect sputum for quantity, odor, color, and consistency; document
findings
- Place patient in high fowlers position
- Teach patient relaxation techniques to reduce anxiety that may cause
shallow or rapid breathing
3. Deficit Fluid Volume R/T increased insensible loss occurring with diaphoresis,
tachypnea, or fever AEB pt is sweating, BUN is 24
- Assess I&O
- Weigh patient daily at the same time of day on the same scale
- Administer fluids as ordered by HCP, Encourage fluid intake
- Promote oral hygiene, including lip and tongue care
- Provide humidity for oxygen therapy
4. Activity Intolerance R/T imbalance between oxygen supply and demand due to
inefficient work of breathing AEB pt becomes short of breath upon ambulation on the
unit.
- Monitor patients respiratory response to activity including assessment of
oxygen saturations
- Maintain prescribed activity levels, and explain rationale to patient
- Allow 90 minutes of undisturbed rest. Facilitate coordination across health
care providers
- Assist patient with ambulation and ROM exercises
- Request consultation from pulmonary rehabilitation
5. Anxiety R/T threat of biologic integrity secondary to multiple disease processes AEB
trembling, insomnia, dry mouth, and patient states I am anxious.
- Assess level of anxiety (mild, moderate, severe, or panic) q shift

Provide a quiet, non-stimulating environment with soft lighting

Administer anti-anxiety medications as ordered
Provide back rub when patient exhibits S/S of increased anxiety
Teach relaxation techniques when patient is not anxious (i.e. guided
imagery, tapes)

SUFFOLK COUNTY COMMUNITY COLLEGE NURSING PROCESS PLAN

Student: Jennifer Altenburg
Patient Initials: PG
Date: 11/12/16
ASSESSMENT DATA FOR NURSING DIAGNOSIS: Pt has a PMH/PMI significant for COPD, PN, and Seizures which
are contributing factors to Impaired Gas Exchange. ABGs show fully compensated metabolic acidosis. Assessment reveals
pt A&O X4, pt on 02 @ 2lpm via NC, Pt VS are temp of 98.1 oral, HR 82, BP 111/66 in R arm, SPO2 is 94%. Auscultation
of lungs reveal diminished breath sounds and bi-lateral wheezes, chest expansion is equal bi-lat. Pt is anxious with no SOB.
Pulses present, regular and strong in all four extremities, skin is warm, pink and dry, capillary refill < 2 seconds.
NURSING DIAGNOSIS / COLLABORATIVE PROBLEM
Impaired Gas Exchange R/T altered oxygen supply and alveolar-capillary membrane changes occurring with inflammatory
process and exudate in the lungs AEB positive CXR and CT of chest showing bi-lateral infiltrates of upper and lower lobes,
cough, diminished breath sounds with wheezes upon auscultation.
DESIRED OUTCOME/GOAL
Patient will exhibit adequate gas exchange and ventilatory function AEB RR <20, no SOB, SPO2 > 95% on RA, and no
adventitious lung sounds
Time Frame: By end of hospitalization
NURSING INTERVENTION
Assess for and promptly report S/S of
respiratory distress

Auscultate breath sounds at least q2h

or as indicated by patient condition

Administer antibiotics as prescribed by

HCP

Monitor ABG results

Teach patient to maintain optimal

EVIDENCED BASED
S/S of respiratory distress include
restlessness, anxiety, mental status
changes. Shortness of breath,
tachypnea, and use of accessory
muscles of respiration. Respiratory
distress necessitates prompt medical
intervention (Swearingen, 2012).
Decreased or adventitious sounds
(e.g., crackles, wheezes) can signal
potential respiratory failure that
would further aggravate hypoxia and
necessitate prompt intervention
(Swearingen, 2012).
Early administration of antibiotics
decreases inflammatory response in
the lung, promoting healing, and
reducing the risk of mortality.
(Swearingen, 2012)
Acute hypoxemia (PaO2 less than 80
mm Hg) often indicates need for
oxygen therapy. Hypocarbia (PaCO2
less than 35 mm Hg), with a resultant
respiratory alkalosis (pH greater than
7.45) in the absence of an underlying
pulmonary disease, is consistent with
pneumonia (Swearingen, 2012).
This intervention promotes drainage

EVALUATION
Pt is anxious, but has no S/S of
respiratory distress at this time.

Auscultation reveals diminished breath

sounds and wheezes bi-laterally, Chest
expansion is equal bi-lat.

Zosyn administered via IVPB per HCP

order, infused well, no S/S of distress

ABGs indicate fully compensated

metabolic acidosis

Pt is maintained in high fowlers

positon (HOB elevated, change

position q2h)

and lung re-expansion and facilitates

alveolar perfusion (Swearingen,
2012).

position, T&P q2h

ACTUAL OUTCOME EVALUATION:

Met Not Met
Specific recommendations for plan modification if needed: Pt is improving at this time, most recent CXR on 11/9 shows
improvements of infiltrates in upper and lower lobes. Pt should finish course of Zosyn as prescribed by HCP. Continue to
monitor interventions for continued improvement.

Focused Nursing Notes

D: Anxiety R/T threat of biologic integrity secondary to multiple disease process. Pt. states I am
anxious A: Pt medicated per HCP order with Xanax. R: Medication had positive effect as patient states
I am less anxious and resting comfortably, will continue to monitor. J Altenburg-Student Nurse
D: Pt A&O X3, PERRLA, appropriate behavior and communication. Pt is on seizure precautions d/t
known seizure disorder. A: Seizure precautions in place, side rails are padded and bed in lowest position.
R: Pt remained seizure free for entire shift, will continue to monitor. J Altenburg-Student Nurse
D: Pt respirations are regular and unlabored. Auscultation of lungs reveal diminished breath sounds with
bi-lat wheezes. Chest expansion is equal bi-lat. Patient has productive cough and is on 02 @ 2 lpm via
NC. A: Pt medicated with mucomyst per HCP order R: Pt wheezing improved, treatment tolerated well
with no S/S of distress, will continue to monitor. J Altenburg-Student Nurse

Test/Normal Values
CBC
RBC 4.7-6.1 M/ 4.2-5.4 F
Hgb
14-18 M/ 12-16 F
Hct
42-52 M/ 37-47 F
WBCs
5000-10,000
Platelets 150,000-400,000
BMP
Sodium
135-145
Potassium
3.5-5
Chloride
95-105
Glucose
70-110
CO2
22-26
Calcium
8.5-10.5
BUN
10-20

Client Values

Significance to Patient Care; Assessment/Interventions

4.45
14.7
43.1
9.4
356

Normal
Normal
Normal
Normal
Normal

135
4.2
102
123
23
8.4 (L)
23 (H)

Creatinine
Magnesium
Albumin

1.09
N/A
N/A

Normal
Normal
Normal
High-monitor lab values and consult HCP
Normal
Low-hypocalcemia may cause tingling pt c/o tingling in hands
High-Dehydration, encourage pt to increase PO fluids of no change
consult HCP for fluid order
Normal
N/A
N/A

UA
pH
S.G.
Color
Glucose
Protein
Ketones
RBCs
COAGS
PT
PTT

0.6-1.2
1.5-2.5
3.5-5

4.6-8
1.010-1.025
Amber
None
None
None
<5
10-13 sec
25-35 sec

7.5
1.014
Yellow
Negative
Negative
Negative
<5
N/A

Normal
Normal
Normal
Normal
Normal
Normal
Normal
Pt. not on anticoagulation therapy. Pt. has order for sequential teds f
DVT prophylaxis.

INR
ABG

pH 7.35-7.45
CO2 35-45
O2 >80
HCO3 22-26
O2 Sat >95%
Cardiac Enzymes
Troponin
Myoglobin
CK-MB
Drug Levels
Phenobarbital

7.36
34
98
19.2 (L)
98

Fully Compensated Metabolic Acidosis-contact HCP, consider HCO

replacement, treat cause may be d/t liver damage, or S/E of medicat
Normal
Alkalotic
Normal
Acidotic
Normal

0.015
N/A
402 (H)

Normal
N/A
High-

15.3

Therapeutic levels for Phenobarbital are 11.5-40 ug/mL. Pt is at a

therapeutic level.

C&S Report
Sputum Culture 11/8

Gram + cocci
in clusters

Gram + Bacteria treat with Zosyn

Positive
Positive

Bi-lat infiltrates of upper/lower lobes

Improvement of infiltrates

Positive
Negative

Possible PE, chest CT ordered to R/O

Negative for PE

Radiological Exams
CXR-11/6
CXR-11/9
Other
D-Dimer 11/6
Chest CT 11/7

Medication/
Classification

Indications

Safe Dose

Major Side Effects

Nursing Implications (Lab

Work, Patient Teaching,
Parameters, etc.)

Piperacillin/Tazobactam
(Zosyn)
-Anti-infective

-Community
Acquired and
nosocomial
pneumonia

-IV 4.5g q 6 hr

-seizures
-c. difficile
-Stevens Johnsens
syndrome

Lacosamide (Vimpat)
-Anticonvulsant

-Treatment of partialonset seizures as

monotherapy or
adjunct therapy

-100 mg twice
daily, may be
increased
weekly by 100
mg/day in two
divided doses

-suicidal thoughts
-dizziness
-headache
-hallucinations

Phenobarbital
(Luminal)
Anticonvulsants,
sedative, hypnotics

-anticonvulsant in
tonic-clonic and
partial seizures

-1-3mg/kg/day
as a single dose
or 2 divided
doses

-hangover
-laryngospasm
-angioedema
-serum sickness

-assess pt for infection

-obtain C&S
-monitor bowel function
-evaluate renal and hepatic
function, CBC, serum
potassium, and bleeding
times prior to and during
therapy
-teach pt to notify HCP if
fever and diarrhea occur
(Vallerand, Sanoski, &
Deglin, 2017).
-monitor for changes in
behavior
-assess patient for skin rash
-monitor CBC and platelets
-teach pt and family risk for
suicidal thoughts (Vallerand,
Sanoski, & Deglin, 2017).
-monitor respiratory status,
pulse, and BP and S/S of
angioedema
-hepatic, renal function and
CBC monitored periodically
-teach pt to notify HCP is
S/S of angioedema, fever,
sore throat, mouth sores
occur (Vallerand, Sanoski, &
Deglin, 2017).

Acetlycysteine 20%
(Mucomyst)
-mucolytic

-management of
conditions associated
with viscous
secretions

-3-5 mL of 20%
solution 3-4
times daily

-vasodilation
-bronchospasm
-hypotension
-tachycardia

-assess for N/V and urticaria

-assess respiratory function,
color, amount, and
consistency of secretions
before and immediately after
treatment
-instruct pt to clear airway
by coughing deeply before
treatment (Vallerand,
Sanoski, & Deglin, 2017).