University of Tabuk

Faculty of medical Applied sciences

Nursing Department
Care Plan

Client Initials: RA Student name: Haya Rashied Albalawi ID: 421000563 Date: 17/9/2022

Assessment Nursing DX/Clinical Client Goals/Desired Nursing Evaluation

Problem Outcomes/Objectives Interventions/Actions/Orders and
(with time scale) Rationale
Subjective (1p) Problem(1p) Long Term: (1p) (1p) Independent: (1p)
• Avoiding complications after surgery.
“loss hearing” • Client Avoid the complications after surgery.
• Monitor and record vital signs closely.
Loss hearing.
In arabic “‫فقدان‬ • client will gain hearing acuity as R : A normal response to pain is an increase in respiratory
evidenced by the ability to understand rate, heart rate, and blood pressure; fever may cause
‫ "للسمع‬verbalized and respond to questions and absence discomfort. • client gained hearing acuity as
of infection and perforation of ear.
by the client’s • Assess pain response using a scale of 1 - 10 q8d. evidenced by the ability to understand
Pain scale measures the changes in the level of pain
family. • avoidance of re-infection. and respond to questions and absence
by different providers.
of infection and perforation of ear.

Objective (1p)
R/T(0.5p) Short Term: (1p) (1p) • Npo midnight before surgery with d5.1/2
• Client avoid of re-infection.
40ml/hr during fasting.
Helps reduce the possibility of postoperative complications
In ammation and increased
• High temperature.
pressure in the middle ear leads to • client Relieving pain and and promotes a rapid return to normal body function. (1p)
otitis media with effusion. discomfort. • Discuss individual postoperative pain management
• Insomnia.
plan and Identify misconceptions client’s parents may

• Otoscopic examination
have and provide appropriate information. • client Relieved from then
Increases likelihood of successful pain management.
reveals presence of • asses the client for surgery. pain and discomfort.
in ammatory changes in
• Provide opportunity to practice coughing, deep-
the middle ear.
breathing, and muscular exercises.

• Encouraging proper discharge Enhances learning and continuation of activity postoperatively.

• Culture & sensitivity of
the ear discharge reveals AEB(0.5p) preparation and health Collaborative: • Client Encouraged proper
of micro-organisms. discharge preparation and
education. • Administer ibuprofen (7.5 ml) q2d.
- episodes Crying While pulling at ear. Analgesic such as acetaminophen and ibuprofen alter health education.
response to pain.

Vs Dependent:
P: 95
• Client Administered to OR for bilateral myringotomy
BP : 105/ 60
with tympanostomy tube placement surgery.
T : 38.7
performed to treat recurrent otitis media (infections that take
O2 : 98 place behind the eardrum) and chronic otitis media (keeping
uid behind the eardrum).

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 University of Tabuk
Faculty of medical Applied sciences
Nursing Department
Care Plan

Client Initials: AF Student name: Haya Rashied Albalawi ID: 421000563 Date: 12/9/2022

Assessment Nursing DX/Clinical Client Goals/Desired Nursing Evaluation

Subjective (1p)
• Client said she’s having
trouble breathing
In arabic “ ‫" صعوبة في التنفس‬.
Problem Outcomes/Objectives Interventions/Actions/Orders and
(with time scale) Rationale
Problem(1p) Long Term: (1p) (1p) Independent: (1p)
• Auscultate breath sounds. Note adventitious breath
• Patient will maintain optimal sounds like wheezes and crackles.
After 3 days of interventions, nursing
• Ineffective airway clearance. breathing pattern, as evidenced by Some degree of is present with bronchospasm obstructions in
relaxed breathing, normal the client was able to demonstrate
airway and may be manifested in adventitious breath sounds.
respiratory rate or pattern, and behaviours to improve airway
absence of dyspnea.
• Elevate head of the bed, have patient lean on over bed clearance.
table or sit on edge of the bed.

Elevation of the bed facilitates respiratory function by use of gravity.

Objective (1p)
R/T(0.5p)
• Cough.
• Use of accessory muscle.
• Loss of consciousness.
• Abnormal breath sounds.
• apneic episodes.
• increased production of
secretions.
Short Term: (1p)
• preventing the hypersensitivity reaction.
• controlling the allergens.
• maintaining airway patency and
preventing the occurrence of reversible
complications.
(1p)
• assist with abdominal / pursed lip breathing exercises.
Provides patient with some means to cope with or control dyspnea and
reduce air tapping.
(1p)
• Keep environmental pollution to a minimum like dust
smoke and feather pillows, according to individual
situation.
Precipitators of allergic type of respiratory reactions that can trigger or
exacerbate onset of acute episode.
• Client get prevented from
• Assist measures to with improve effectiveness of
cough effort. hypersensitivity reaction.
Coughing is most effective in an upright position after chest percussion.

• VS as been follows
AEB(0.5p) • Increased uid intake to 3000ml/ day and provide • The allergens get controlled.
P: 82 warm liquids.
• intermittent episodes of Hydration helps decrease the viscosity of secretions, expectoration.
BP 110/80
facilitating Using warm liquids may decrease bronchospasm.
T: 37.1 wheezing.
Collaborative:
• The airway patency get
O2: 88
• dyspnea.
• Administer Albuterol (Proventil, Ventolin). as maintained and prevented the
prescribed.
Short-acting beta2-agonists are bronchodilators , They relax the occurrence of reversible
• decreased oxygen saturation. muscles lining the airways that carry air to the lungs.
complications.
• Inhaled Corticosteroids Budesonide (Pulmicort).
• hypersecretion of mucus.
Corticosteroids reduce inflammation in the airways that carry air to the
lungs and reduce the mucus made by the bronchial tube.

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 University of Tabuk
Faculty of medical Applied sciences
Nursing Department
Care Plan Clinical Worksheet

Client Initials: ________

AF Student: ______________________________
Haya Rashied Albalawi Date of Care: ___________
12/9/2022

Demographic Information Health History Care Prescriptions

Age: ____
40 Gender: ____ F Chronic conditions & previous health Nutrition
Nationality: ____
Saudi problems: Type of diet: __________________________________
No diet
Code Status: ________
Full status • NPO
• Tube Feeds: Type ___________ Rate ________
Weight: ____
60 Height: ____
153 BMI: • G tube • NG tube
____:
25.63the patient is Overweight
_____ • Aspiration risk • Thickened liquids: Type __________
Reason for Admission [patient’s own Unexpected events/complications during Activity: • Independent • Assist • Dependent
words]: hospitalization: N /A • Ad lib • BR only • Chair • Ambulate • Bed Rest
• Client said she’s having trouble breathing • Assistance of ___ (# of people)
In arabic “ ‫" صعوبة في التنفس‬.
Previous surgeries: [type/year] Assistive devices:
Client have not a previous surgery
• Gait belt • mechanical lift • walker • cane
• Other : ________________________________
Medical Diagnosis [medical terms]: Nursing Diagnoses (5, prioritized, with Elimination: • Continent • Incontinent
related factors): • Voiding • Foley catheter • I & O
bronchial asthma • Ine ective airway clearance related to increased • Enema • Colostomy • Other: _____________
production of mucus and bronchospasm. Skin Care:
• Intact skin • Pressure ulcer stage: __________
• Impaired gas exchange related to altered • Other: ________ • Turn & position w/ skin care q. 2 hrs
Date of admission: 12/9/2022 delivery of inspired O2. Wound Care: • Dressing/drain • Drsg. Change/treatment
Location & Type______________________________
Allergies: No allergy
• Anxiety related to perceived threat of death. IV Site: Location ___________
basilic vein medially Size: ___________
24 gauge
• Saline Lock : after therapy completed
• IV Fluids: Magnesium
_____________
sulphate Rate: 120
___________
mg / min

Pulmonary care:
Other notes: N/A • O2 ___ L/min via • N/C • mask • on room air
• Incentive Spirometer q ___ hrs.

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 • MDI inhaler Mini-neb Med. • albuterol • atrovent
• Other
Glucometer: • ac & hs • other ____________
• sliding scale insulin, every ______hours

Discharge Plan/Long Term Needs:

• emphasize adherence to the prescribed therapy, preventive
measures, and the need to keep follow-up appointments with
health care providers. Teach patient how to implement an action
plan and how and when to seek assistance.

Teaching Needs:
• Teach patient and family about asthma (chronic inflammatory),
purpose and action of medications, triggers to avoid and how to
do so, and proper inhalation technique. Instruct patient and
family about peak-flow monitoring. Obtain current educational
materials for the patient based on the patient’s diagnosis,
causative factors, educational level, and cultural background.

Medications (scheduled & prn)

Name/Dose/Route Class & Action Major Side Effects Nursing Implications Patient Education
Propranolol , 90mg/q2d / oral ask your doctor or pharmacist to explain any part you do not understand. Take
beta blockers ,reduces heart rate Aggravated congestive heart failure Assess heart rate, ECG, and heart sounds, especially during exercise
propranolol exactly as directed. Do not take more or less of it
use caution with renal insu ciency, muscle weakness, monitor EKG and Take each dose with a full glass (8 ounces or 240 milliliters) of water unless
MgSO4 , 1g/q6hr ,IV respiratory status, monitor Mg levels, Calcium gluconate is the antidote. your doctor directs you otherwise.

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Lab Values & Diagnostic Test Results

a. Important lab tests to monitor Why? (Consider diagnosis, pre-existing conditions, medications, complications, etc.)
ABG show signs of acute alveolar hyperin ation with hypoxemia
Hematology for the presence of eosinophils
Chest X-ray show an increased A-P diameter, dark (translucent) lung elds, and attened diaphragms

b. Hematology Normal values Patient’s Values (include serial labs) Significance for this patient
Date Date Date
WBC 4000 - 11,000 12/ 9 /2022 16/ 9 / 2022 6250
Plt 12.0 - 40.0 12/ 9 /2022 16/ 9 / 2022 24.6
Hgb 11.3 - 16.0 12/ 9 /2022 16/ 9 / 2022 15.4
Hct 44.5 - 34.9 12/ 9 /2022 16/ 9 / 2022 37.3
RBC 370-550 12/ 9 /2022 16/ 9 / 2022 529

c. Chemistry Normal values Patient’s Values (include serial labs) Significance for this patient
K+
Na+
Cl-
CO2
BUN
Cr
Glucose
Albumin

d. Coagulation Normal values Patient’s Values (include serial labs) Significance for this patient
PT
INR
PTT

e. Urine Normal values Patient’s Values (include serial labs) Significance for this patient
Color
Appearance
Spec. gravity
PH

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 Glucose
Ketones
Nitrates
RBCs
WBCs
Casts
Protein

f. ABGs Normal values Patient’s Values (include serial labs) Significance for this patient
pH 7.35 - 7.45 12/ 9 /2022 16/ 9 / 2022 7.585
PaCO2 35-45 12/ 9 /2022 16/ 9 / 2022 55
HCO3 22 - 26 12/ 9 /2022 16/ 9 / 2022 12.8
PaO2 100 12/ 9 /2022 16/ 9 / 2022 75
SaO2 93% - 98% 12/ 9 /2022 16/ 9 / 2022 78% RA

g. Other Normal values Patient’s Values (include serial labs) Significance for this patient

h. Pertinent radiological studies:

bronchial wall thickening
expiratory air trapping
inspiratory decreased lung attenuation
small centrilobular opacities
bronchial luminal narrowing: reduced bronchoarterial-diameter ratio
subsegmental bronchiectasis
i. Other diagnostics (e.g. ECG, EEG, echo):
N/A

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Patient Assessment & Nurses Notes

VS: (P,T,RR,BP,PO2,Pain)
P: 82 , BP 110/80 , T: 37.1 , O2: 88 , 3/10 on pain scale

Neuro: (GCS, Pupil size,….)

N/A

Musculoskeletal: (Strength, movement, coordination,….)

Weakness , head and shoulders more forward and had lower chest wall expansion,
decreased shoulder internal rotation, and decreased thoracic spine exibility.
Chronic lower thoracic, cervical, and shoulder pain was signi cantly increased

Skin: (Color, warmth, texture, abnormalities,…)

White intact skin no breaks, scrapes, cuts, or abnormal openings that allow pathogens to enter.

Cardiac: (Cardiac & peripheral pulses for rhythm, sounds, strength,…)

P: 82 , regular rhythm , normal s1 and s2 sounds .

Pulmonary: (auscultation, airway clearance, breathing pattern, respiratory therapy,…etc)

Weezing , Ine ective airway clearance , thoracic breathing ,Inhalation therapy with bronchodilators (relievers) and anti-in ammatory agents

GI/Nutritional Status: (appetite, food consumption, bowel sound, bowel motion, NPO status, type of diet, disorders,..)
Loss of appetite , no diet , Bowel sound consist of clicks and gurgles and 5-30 per minute.

GU/Reproductive: (Continence, abnormalities,…)

N/a

Psychosocial: (anxiety level, social interaction, family support, body image, psychological disorders,…)

mild anxiety ,A personal or intimate relationship occurs. 18

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Date/Tim Nurses Notes
e
12/9 , 9:00am Patient is a 40 year old female , admitted on 12-9-2022 with sever bronchial asthma. She came in from ER with hypoxia , decision was made to have a non rebreather mask. She is alert and

oriented to person only , she reports no pain and 0 om a 0 -10 pain scalw , heels are elevated with SCD’s on bilaterally. No edema noted on extremities. Baseline vital signs are : respiratory 18

, blood pressure 110/80, Sao2- 78% . HR: 82. She is on 10L of oxygen via non rebreather mask and slowly weaning off , she has intermittent periods of heart rate in the 30’s . All pulses are

of moderate streams. Lung sounds diminished. No adventitious sounds projected, she is on telemetry , she defecates in a brief . Last BM was on 14-9-2022. She is on bed rest . PT and OT

have been working with her . Full assistance is needed for q2h turning, repositioning and eating . She have no diet , she ate 70% of her breakfast and 100% of her lunch, she don’t have

dif culty swallowing. Will need a referral for speech therapist as well as radiology. Urine 400ml from 0730-1400. Urine is amber and cloudy . He drank 250mL of uid from 0730 to 1400 .

Continue to monitor. Peripheral iv 20g catheter in right forearm. Flushed and currently infusing normal saline 0.45% at 125mL/hr

Note: Nurses Notes are for additional information not included in the assessment or worksheet, such as events or procedures done during the shift.
Do not just repeat assessment information or list routine care included in the worksheet or that would be charted on flow-sheets.

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