Reflections: MANAGE NURSING CARE AT HOME, "...Care Plan Example"

APPENDIX 5: NURSING CARE PLAN EXAMPLE

The following is an actual care plan submitted by this writer [DRB] while in nursing school. It is provided to illustrate nursing care plans. Some information has been altered or deleted for patient confidentiality. [Bracketed material added editorially here.]

Name: Diane Beggin Date: 04-11-02 Client: E.J. MedDx: Syncopal Episodes, Acute Renal Failure, Possible Pneumonia

Nsg Dx: Impaired Gas Exchange related to decreased functioning lung tissue, chemotherapeutic agents, decreased immune response and congestion secondary to recent thoracotomy of mesothelioma (diagnosed in 10/2001), chemotherapy Gemcitabine and Cisplatin.

Defining Characteristics: As Evidenced By – increased respiration rate typically above 20 up to 28-34 breaths per minute (normal = 16-20) noted intermittently but usually upon restlessness or exertion at bedside; audible breath sounds without auscultation indicative of fluid congestion in lungs; ineffective, unproductive cough with retained secretions; decreased oxygen saturation of 92% on 2L oxygen via nasal cannula (normal with room air is 96% plus). Lab values: hyper- to hypocapnia [high to low levels of carbon dioxide in the blood] (20-32 when normal limits are between 22-29); hypoxemia [low levels of oxygen in the blood] (74 when normal is between 80-100); decreased hemoglobin (9-10 when normal is between 13.5-17), decreased hematocrit (28-31% when normal is 41-53%); decreased erythrocytes (3.6-3.7 when normal is 4.7-6.1). Mental status: restless intermittently; confusion “Is WWI over?” WWII? “What war is going on now?” “Am I still at City Hospital? (When that hospital was in a different state in a different part of the country.)

Outcome: Client will have increased gas exchange within four days as evidenced by: decreased confusion and restlessness; increased level of consciousness; decreased dyspnea at rest and upon exertion in 24 hours or less; decrease in adventitious [unusual, non-normal] breath sounds especially those heard without auscultation; ABGs with normal ranges; increased sputum to relieve congestion.

Interventions [I] & Rationales [R]:

1) I: Assess lungs every 2 hours minimum or upon changes. Assess for unauscultated [not sensed by a stethoscope] audible and auscultated congestion. Note type and presence of adventitious lung sounds as well if diminished. (Assessed with wheezes bilaterally, crackles especially to left base, diminished on right and unknown to what extent lung was dissected). Note location.

R: Frequent assessment lends to knowledge of progressing or resolving problems and provides increased time to act. Noting specifics provides baseline for self and others to use for comparison in evaluation of treatment.

2) I: Assess rate and quality of respirations every 2 hours. Look for increases in signs of dyspnea such as nasal flaring, shallow respirations, tachypnea, increased confusion and restlessness, decrease in capillary refill (currently normal) and decreased peripheral pulses (present currently).

R: All are additional signs of lack of oxygen via gas exchange. Some provide details of progression to other systems such as the periphery if changes occur.

3) I: Monitor neurological functions every 2 hours. Establish baseline for level of consciousness, papillary response, response to sensation, command response. Provide simple commands in which he can follow. Orientate as necessary.

R: After initial assessment, baseline provides gauge upon which to further assess. Level of consciousness is primary indicator. Already has decreased function to time and place. Can easily lose track of times especially with currently prescribed medications. Helps to provide recognition to surroundings and focus.

4) I: Ensure oxygen is provided as ordered. Check position of cannula and skin to ensure no breakdown. Collaborate with respiratory therapy to ensure treatments are completed as ordered. Follow up on arterial blood gas orders.

R: With decreased oxygen to tissues, integrity of skin can diminish, increasing risk for infection. Ensures proper placement to ensure therapeutic measure. Ensures treatments are received timely and do not interfere with other diagnostic tests or treatments. Values essential to provide meaningful and therapeutic treatments.

5) I: Elevate hard of bed to roughly semi-fowler’s position or as is comfortable for client. Ensure proper precaution (use of pillows, flexion at knee, etc.) to decrease shearing forces especially with lack of energy to prop self up and prevent sliding.

R: Provides increased oxygenation by decreasing pressure on diaphragm and result in ease of breathing. Position helps with problems with hypoxia and hypoxemia.

6) I: When conscious and alert, encourage deep breathing. Find ways to enhance client participation (for example, washing feet makes him more alert; smiling at him evokes the same response). At those times, instruct him to deep breathe and mime it for him. Provide splinting for his coughing as he had decreased energy and awareness to do it himself.

R: Client is cooperative. When alert, encouraging and taking deep breaths with him may decrease avoidance or increase mimic activity. Due to confusion, splint abdomen for him to illustrate. Continue to do so when can each time, doing these exercises until he can accomplish them for himself.

7) I: Ensure suction equipment is accessible.

R: Provides readiness in negative circumstances.

8) I: Encourage fluids as appropriate. Client has no IV except for pharmacological treatment and is on a renal diet. For comfort, provide mouth care every 2 hours if not more.

R: Without fluids mouth becomes very dry. Also on antibiotics with increased risk for thrush increased with leukocytopenia [a decrease in the white blood cells]. Mouth care provides freshness, comfort, hygiene, and opportunity for assessment,