Care Plan Week 5 2
Student Name: __Shelley Birdwell___________________________________Date:_____5/6/2015_________ Patient’s Initials: ___L.A__ Age: ___78_ Medical Diagnosis: _CHF________________
Subjective Data: He has loose watery stool for the past 12 hours, CHF, perineal area has become excoriated and tender.
Objective Data (Head to Toe Assessment including Vital Signs): SOA, pulse oximetry reading is 88%, bilateral crackles in the lower lobe, BP102/60-T 101 F, P 104, RR 32, he is receiving IV fluids @ 80 ml/hour.
Nursing Diagnosis:
Excess fluid volume R/T CHF AEB pulmonary congestion, adventitious breath sounds
Patient Goals/Objectives (What do you hope will be the result of your efforts? Make sure goal is patient oriented, measurable, and has a time frame).
Planned Interventions: (What is indicated for the management of this particular problem? Name three priority interventions making at least one patient teaching).
Rationale: (Why/How does the intervention work?) Cite page number and source for each intervention.
Evaluation of Patient Goals:
(Was patient’s goal met/ not met/ ongoing? Why/why not? List evaluation criteria. If intervention is ongoing, list what patient has accomplished.
Short Term:
Patient will have clear lung sounds in 3 hours after diuretic, bronchodilators, and isotropic agents are administered.
Demonstrate adequate ventilation and oxygenation of tissues by oximetry with in clients normal ranges and be free of symptoms of respiratory distress before end of shift
1. Monitor breath sounds, noting decreased or adventitious sounds
2. Oxygen administered via nasal cannula
3. Administer medication, as indicated, such as the following: diuretics, such as Lasix
1. Excessive fluid volume often lead to pulmonary congestion
2 Keep O2 sat above 90%
3. Reduce pulmonary congestion, enhancing gas exchange.
1. Identify relationship of ongoing therapies to reduction of recurrent episodes and prevention of complications.
2. Demonstrate uncompromised Respiratory
Subjective Data: He has loose watery stool for the past 12 hours, CHF, perineal area has become excoriated and tender.
Objective Data (Head to Toe Assessment including Vital Signs): SOA, pulse oximetry reading is 88%, bilateral crackles in the lower lobe, BP102/60-T 101 F, P 104, RR 32, he is receiving IV fluids @ 80 ml/hour.
Nursing Diagnosis:
Excess fluid volume R/T CHF AEB pulmonary congestion, adventitious breath sounds
Patient Goals/Objectives (What do you hope will be the result of your efforts? Make sure goal is patient oriented, measurable, and has a time frame).
Planned Interventions: (What is indicated for the management of this particular problem? Name three priority interventions making at least one patient teaching).
Rationale: (Why/How does the intervention work?) Cite page number and source for each intervention.
Evaluation of Patient Goals:
(Was patient’s goal met/ not met/ ongoing? Why/why not? List evaluation criteria. If intervention is ongoing, list what patient has accomplished.
Short Term:
Patient will have clear lung sounds in 3 hours after diuretic, bronchodilators, and isotropic agents are administered.
Demonstrate adequate ventilation and oxygenation of tissues by oximetry with in clients normal ranges and be free of symptoms of respiratory distress before end of shift
1. Monitor breath sounds, noting decreased or adventitious sounds
2. Oxygen administered via nasal cannula
3. Administer medication, as indicated, such as the following: diuretics, such as Lasix
1. Excessive fluid volume often lead to pulmonary congestion
2 Keep O2 sat above 90%
3. Reduce pulmonary congestion, enhancing gas exchange.
1. Identify relationship of ongoing therapies to reduction of recurrent episodes and prevention of complications.
2. Demonstrate uncompromised Respiratory
References: (Use your textbook or any other reputable source. Wikipedia is not a reputable source. Cite your references in APA format): 1. Ahern Nancy R. & Wilkinson Judith M. Nursing Diagnosis Handbook. 9th edition. p 25-31. Publisher Alexander Julie Levin. 2009 2. Doenges Marilynn E., Moorhouse Mary Frances & Murr Alice C. Nursing Care Plans. 9th edition. p 51-54. Publisher Davis F.A 2014 3.Doenges Marilynn E., Moorhouse Mary Frances & Murr Alice C. Nursing Pocket Guide. 12th edition. p 69-73 p