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Nursing Care Plan

Nursing Care Plan

Impaired Dentition Nursing care plan

Student name
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Nursing Care Plan

Section A-Assessment
Step 1

Patient Information Form

(Adapted from Canadian Neighbourhood)

Biographical Data

Gender: M Age: 78

Patient living at home or in residence: Resident

In-Patient Unit /hospital (type of unit): Emergency

Admission Date: May 15th, 2021

Date of Assessment: May 15th, 2021

Allergies: No existing information

Social History: No existing information

Supports: Has family (two brothers and a son)

History

Presenting problem/Chief Concerns:

Vital Signs and lab report as soon as arrive in hospital:

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Temp : 37 DC at Resident , 35.6 DC at hospital (hot)

PR : 45 beats/min

BP : 80/70 mmHG

RR : 15

O2Sat : 83% (O3 at 3L/min)

Lab results : Regular apart

Vital Signs during staying in the hospital:

HR : 144 beats/min (Tachycardia)

RR : 36 at resting (Tachypnea)

O2Sat : Dropping to 82% (O2 at 5L/min via NP)

Hgb level : continued to drop to 72 (Blood transfusion of 1 unit PRBC x 2 were given)
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History of presenting problem (signs, symptoms, onset etc.):

Signs:

Low Blood Pressure

High temperature

Low pulse rate

Low oxygen saturation

Difficulty Swallowing

Coccyx pressure – stage 1 – Due to immobility

Symptoms :

Shortness of breath

Poor appetite

Diarrhea

Nausea

Constipation

Urinary incontinence

Weight loss

Sleeping disorder

Weakness and fatigue

Confusion and hallucinations

Sore throat

Headache

Back pain

Feeling chills and hot

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Past medical and surgical history:

Past Medical History:

HTN, hyperlipidemia, gout, kidney disease, right ventricle cardiomegaly (enlarged heart),
osteoporosis, degenerative knee ligaments with chronic pain, anemia NYD, anxiety and cognitive
impairment, history of falls

Past Surgical History: No data available

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Current Medications and Treatments:

Reason patient is
Medication Dose Route Frequency
taking

To lower high
Allopurinol 200 mg PO 1 daily uric acid level in
blood

Atenolol 50 mg PO 1 daily High BP

Perindopril 8 mg PO 1 daily High BP

Anxiety and
Mirtazipine 15 mg SL QHS
sleeping

Senekot 8.6 mg PO 1 to 2 QHS Constipation

Certain stomach
and esophagus
Pantoprazole 40 mg PO 1 AC problems

(acid reflux)

Actonel - PO 1 Sundays only Osteoporosis

Medications and Treatments during staying in the hospital:

Reason patient is
Medication Dose Route Frequency
taking

NS - IV @100 cc/hr dehydration

Ceftriaxone 500 mg IV - Pneumonia

NS - IV @75 cc/hr dehydration

Step 2: Actual and Potential Problems

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Actual problems:

Shortness of breath

Pneumonia

Difficulty swallowing her food

Constipation

Urinary incontinence

Dehydration

Delirium

Hyperthyroidism with abnormal level

Potential problems:

Pulmonary hypertension

Thyroid cancer

Back pain

Step 3: Clustering and Prioritizing Date

Respiratory

Breath Sounds - Rate, Rhythm, Depth, Shortness of breath, Fist RR: 18

Characteristics, Adventitious Sounds
During staying in hospital Tachypnea with RR: 36 at resting
O2 Saturation
O2 S: 92%, then during staying in hospital dropped to 82%
Cough (productive or non-productive)
No Data
Secretions
No Data
Suction Requirement
No Data
Oxygen Therapy
First 2L/min, then 5L/min via NP

Cardiovascular
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Apical pulse - rate, rhythm, First PR: 55 beats/min

Heart valves - diaphragm & bell, characteristic Low BP : 90/60mmHG, During staying in hospital Tachycardia
with HR: 144 beats/min

No Data
Capillary Refill
No Data
Edema – description, extent, pitting or non-
pitting

Peripheral Pulses X4 - rate, rhythm, strength, No Data

and equality

Delirium

Hallucinating
Nervous System
Confuse

Moaning

Integumentary

Colour Febrile

Temperature At home 40 DC on Dec 2nd , in Hospital Temp : 38.7 DC

Skin Hydration Dehydrated

Skin Texture Feeling chills and hot on Nov 26th for 2 days, experiencing rigors

N/A

Elasticity N/A

Skin Turgor No

Lesions Stage 1 coccyx pressure injury due to immobility

Wounds No

Scars N/A

Braden scale

Gastrointestinal

Abdomen shape, Scars, Lesions No Data

Bowel sounds No Data

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Palpation No Data

BM – last one, usual bowel patterns Diarrhea on Nov 28th for 3 days

Bristol bowel movement chart Constipation

Continence/incontinence No Data

Height No Data

Weight Lost significant weight

BMI No Data

Diet: No Data

Amount consumed In hospital IV NS @ 75cc/hr resolved fluid intake

Ability to eat Poor appetite and oral intake, difficulty swallowing

Musculoskeletal ROM: On Dec 2nd, she was found on the floor at 12:30 AM
sitting for 2 hours.
ROM
By Dec 4th, she is unable to get out of bed
Ambulatory
No
Mobility Aid
Very weak and fatigue
Limb strength
No
Transfers

Genitourinary During the 4 week hospital stay, she developed urinary

incontinence
Continence/incontinence/catheter
No Data
Urine Assessment – characteristics, amount
No Data
Condition of Perineal Skin
No Data
Discharge/odor

Neurological

Level of Consciousness Confuse, hallucinating, delirium

Orientation No Data

Mental Status She has anxiety, she has been making inappropriate remarks
and talking funny

No Data
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GCS Number She has sister and daughter

Communication No Data

Vision No Data

Hearing

Pain

O = Onset Back pain on Nov 26th for 2 weeks

P = Palliation / Provocation Headache for 2 weeks

Q = Quality/Quantity Sore throat on Nov 6th for 3 to 4 days

R = Radiation / Region

S = Associated S&S

T = Timing

U = Understanding

Last Pain Medication? Tylenol

Effect? Headache was not resolved with Tylenol

Sleep & Rest

Sleeping patterns (#h/d) Difficulty sleeping due to hospital environment

Naps No

Use of sedation Mirtazipine 15mg SL QHS for anxiety and sleeping

Feeling rested? No Data

Psycho-social (SELFACNG)

S – Self-Esteem: pertaining to hygiene, grooming, eye S: Patient has anxiety.

contact, statements about oneself and any other
characteristics that provide information about the E: She is not involved in any social activity.
patient’s self-esteem, Sense of self, in relation to the
L: She was discharged under her daughter’s care
world, Sense of meaning and purpose, Value base,
with LHIN in-home services for PT/OT.
Evidence of Emotional Distress, Grief Issues
F: She has a sister that notices her. She also has a
E – Energy Level: Patient’s with psychological problems
daughter.
often have an alteration in level of activity.
A: She is moaning and confused
L – Lifestyle: Living arrangements, significant
relationships, occupation, hobbies or lack of interest in
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Nursing Care Plan

leisure activities, education, and any other data that C: Culture and religion are not mentioned.
provides information about the patient’s personal
situation. N: Not Mentioned by the patient

F – Family System: contact and support from family G: Not Mentioned by the patient
members or significant others, family stressors, crisis
events, and usual coping skills.

A – Affect: mood or emotional feelings. It may be

described as happy, euphoric, flat, inappropriate, and
other descriptive terms.

C – Culture: refers to all cultural, racial, or anthropological

variables that influence one’s lifestyle and mental health,
may refer to issues of homelessness, religious and
spiritual preferences, if any. Discuss any related food
needs and other areas of impact spirituality will have on
their health status. I – Interests: Hobbies and other
activities enjoyed

N – Needs: As expressed by the patient

G – Goals: As expressed by the patient

Tubes Insitu

IV / central line / PICC, Foley catheter, NG, In ED, she was started on IV NS @100cc/hr via PIV
PEG/G-tube, drains
Ceftriaxone 500 mg IV for the pneumonia
(IV site, solution, rate)
During staying in hospital, IV NS @75cc/hr resolved her fluid
intake

Lab Values All normal except:

(as soon as arrived in hospital) Hgb = 112

Na = 144

Creatinine level = Elevated

Lab Values

(during staying in hospital) Hgb = 72 (Blood transfusion of 1 unit PRBC x 2 were given)
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Step 4: List of Priorities

Respiratory Cardiovascular
● Shortness of breath ● Low BP (90/60mmHG)

● Tachypnea with RR: 36 at ● Tachycardia with HR: 144

resting beats/min

● Low level of O2 saturation

Gastrointestinal Integumentary
● Difficulty swallowing ● Febrile (high temperature)

● Poor appetite ● Dehydration

● Constipation ● Stage 1 coccyx pressure

injury
● Lose significant weight

Step 5: Judgments and Inferences

Clinical judgement and inference is based on understanding the actual problems and issues and also
certain concerns of the patient. I read this case study carefully and found the actual problems with
symptoms such as shortness of breath, confusion, poor appetite, difficulty swallowing, diarrhea, nausea,
high temperature, weakness and fatigue. Therefore, patient diagnosis was COVID pneumonia and
bilateral bacterial pneumonia.
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Nursing Care Plan

Section B-Nursing Diagnosis

Step 6

P-problem

● Ineffective Breathing Problem

E-etiology

● COVID-19/pneumonia
S-signs and symptoms

● Shortness of breath
● O2 sat @ 92% dropping to 82% (room air)
● Tachypnea with RR=36
● Febrile 40C upon admission
● Positive COVID-19 test

Nursing Diagnosis Statement (PES Statement)

Ineffective breathing pattern related to community acquired COVID-19 as evidenced by SOB,

O2 sat @ 92% and dropping, tachypnea (RR=36), febrile, + COVID-19 test.

Two problems from the list of priorities related to the topic/contents in the course;

● Gastrointestinal-difficulty swallowing, poor appetite, constipation, weight loss related to

the topic of Nutrition (chapter 42-Potter and Perry)
● Integumentary-stage 1 coccyx pressure injury related to the topic of Pain-Nociceptive
(chapter 31-Potter and Perry)
Step 7

Signs and Symptom’s (defining characteristics) for the diagnosis.

● Shortness of breath
● Hypoxemia
● Tachypnea
● Febrile
● Positive test result for COVID-19
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Section C-Nursing Outcomes

Section D-Nursing Interventions

Step 8

Nursing Care Plan (Outcome/Goals)

Ineffective breathing pattern related to shortness of breath

1. The patient will be able to maintain effective breathing pattern and improved airway clearance as
evidence by being able to have respiratory rates between 12 to 20 breaths per minutes, oxygen
saturation above 96%, and verbalize ease of breathing.
Expected Outcome

 Client will maintain a patent airway at all times

 Client will demonstrate ability to perform pursed lip breathing and controlled
breathing
 Client will demonstrate slow and deep breathing
 Client will verbalize understanding of oxygen supplementation and other
therapeutic interventions.

2. The patient will maintain optimal gas exchange related to pneumothorax as evidence by shortness
of breath.
Expected Outcome

 Client will demonstrate effective coughing and clear breath sounds

 Client will explain methods useful to enhance secretion removal
 Client will identify and avoid specific factors that inhibit effective airway
clearance
 Client will identify potential etiology of fatigue

Step 9

Nursing Interventions and Rationales

Nursing Interventions Rationales

Teach and assist patient with proper deep-
breathing exercises, using demonstration of slow
inhalation, holding end inspiration for a few
seconds, and passive exhalation.
Teach the patient in using pursed-lip and
controlled breathing techniques.
These techniques promote deep inspiration which
increases oxygenation and prevents atelectasis.
Controlled breathing methods may also aid slow
respirations in patients who are tachypneic.
Prolonged expiration prevents air trapping.
(Wayne, 2019)
Spontaneous pursed lips breathing can be a useful
technique to increase walking endurance and
reduce oxygen desaturation during walking in
patients with moderate to severe chronic
obstructive pulmonary disease. (Faager, Stahle, &
Larsen, 2008)

Nursing Care Plan
Evaluate skin colour, temperature, observe central
versus peripheral cyanosis.
Teach the client to identify and avoid specific
factors that exacerbate ineffective breathing
patterns.
Teach the client and family the importance of
maintaining the therapeutic regimen and having
as-needed drugs easily accessible at all times.
Educate the patient and family members of the
transmission of COVID-19.
Elevate the head of the bed, assist the patient into
semi-Fowler’s position.
Turn the patient at least every 2 hours to mobilize
as tolerated.
Assess the patient’s vital sign and characteristics
of respirations at least every 4 hours.
Review medications to determine possible side
effects or interactions effects that could cause
fatigue.
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In central cyanosis, both the skin and mucous
membranes are affected due to seriously impaired
pulmonary function from unventilated or under
ventilated alveoli. Peripheral cyanosis (skin only)
usually indicates vasoconstriction or obstruction
to blood flow. (Ackley, Ladwig, & Flynn Makic,
2017)
Assist the client and family with identifying other
factors that precipitate or exacerbate episodes of
ineffective breathing patterns, e.g., stress,
allergens, stairs, and activities that have high
energy requirements. (Ackley, Ladwig, & Flynn
Makic, 2017)
Appropriate and timely use of medications can
decrease the risk of exacerbating ineffective
breathing. Client/family may need repetition of
instruction received at hospital discharge.
(Ackley, Ladwig, & Flynn Makic, 2017)
Adequate information about COVID-19 and its
management to the patient to prevent the spread of
infection to the patient’s family members,
community, and healthcare providers. (Hetzler,
2020)
Head elevation and semi-Fowler’s position help
improve the expansion of the lungs, enabling the
patient to breathe more effectively. (Ackley,
Ladwig, & Flynn Makic, 2017)
To prevent complications of immobility such as
thromboembolism that may worsen the
pneumothorax and eliminate skin injury. (Ackley,
Ladwig, & Flynn Makic, 2017)
To assist in creating an accurate diagnosis and
monitor effectiveness of medical treatment,
particularly the antibiotics and fever-reducing
drugs administered. (Ackley, Ladwig, & Flynn
Makic, 2017)
Involve the patient and/or family member in vital
sign assessment and the significance of findings
through implementation of teaching plans as
necessary. (Potter, Stockert, Perry, & Hall, 2019)
Older adults report fatigue that limits functional
and can aggravate comorbid conditions. Certain
medications may cause fatigue particularly in
older adults. (Ackley, Ladwig, & Flynn Makic,
2017)
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Nursing Care Plan

Section E-Evaluation and Documentation

Step 11

Evaluation:

Evaluation helps nurses determine if they have met their goals. Evidence for meeting nursing goals in this
case include:

● The patient maintained optimal gas exchange related to pneumothorax as evidence by shortness
of breath
● Restoring to normal breathing patterns: Patient responded well on high flow oxygen during 3
weeks and managed to be weaned off back to room air at time of discharge.
● Patient had improved body temperature levels as she didn’t have any fever when she was
discharged.
● Resolved her dehydration: IV NS@75cc/hr resolved her fluid intake.
● Patient learned more about Covid-19 and its management: She was enrolled in the 2 Covid-19
research studies.
● Patient received a Covid-19 antibody plasma infusion.
● Patient successfully prevented the spread of infection to family, community and healthcare staff.
● Patient was able to reduce anxiety.
● During the clinical shift, the patient is turned q2h to mobilized as tolerated
● The patient’s family and caregivers are educated in skin breakdown prevention before the patient
leaves the hospital and are given ways to prevent pressure ulcers for this patient given mobility

Step 12:

Documentation:

Documentation is so important. It includes individual findings, affecting interactions, cultural and

religious beliefs and expectation, plan of care and responses to interventions.

We as a nurse, need to record vital signs such as blood pressure, pulse, temperature, respiration rate,
oxygen saturation and oxygen therapy during the time that patient is staying in the hospital. We also need
to mention all the symptoms of the patient. For this case, symptoms are shortness of breath, confusion,
poor appetite, urinary incontinence, generalized weakness, fatigue and not sleeping upon discharge. The
initials of the health care professional who assessed and recorded the vital signs need to be indicated in
the “initials” box.

Patient was received a blood transfusion of 1 unit PRBC x 2 to improve hemoglobin level. Patient was
discharged on Dec 28th under her daughter’s care with LHIN in-home services for PT/OT. Discharge
diagnosis of Covid pneumonia and bilateral bacterial pneumonia.
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Also, follow up plans need to be documented. For this patient, follow up with her GP in 2 weeks upon
discharge, check the thyroid levels in 6 months. Endocrinologist and nephrologist follow up in 2 months.
A referral which was sent to the hematologist to check the Hgb levels.

Reference:

Hetzler, L. (2020, July). Nursing Management of Covid-19. Evaluation. Retrieved from

https://everynurse.org/blog/nursing-management-covid-19/

Ackley, B. J., Ladwig, G. B., & Flynn Makic, M. B. (2017). Nursing Diagnosis Handbook (Vol. 11th Ed).
St. Louis, Missouri: Elsevier.

Faager, G., Stahle, A., & Larsen, F. F. (2008, August 22). Clinical Rehabilitaion. Influence of
spontaneous pursed lips breathing on walking endurance and oxygen saturation in patients with
moderate to severe chronic obstructive pulmonary disease, pp. 1.
doi:10.1177/0269215508088986

Hetzler, L. (2020, July 10). Nursing Management of COVID-19. Retrieved March 20, 2021, from
EveryNurse.org: https://everynurse.org/blog/nursing-management-covid-19/

Potter, P. A., Stockert, P. A., Perry, A. G., & Hall, A. M. (2019). Canadian Fundamentals of Nursing
(Vol. 6th Edition). (B. J. Astle, & W. Duggleby, Eds.) Alberty: Elsevier.

Wayne, G. (2019, February 7). Ineffective Breathing Pattern Nursing Care Plan. Ineffective Breathing
Pattern, pp. 1. Retrieved March 20, 2021, from https://nurseslabs.com/ineffective-breathing-
pattern/