Nursing Care Plan
NURSING DIAGNOSIS GOAL INTERVENTIONS RATIONALE EVALUATION impaired Gas Exchange R/T STG: 3/17/2014 throughout shift 1. Auscultate breath sounds 1. Abnormal breathing STG: PT O2 saturation on admission abnormal breathing AEB PT will maintain O2 saturation noting areas of decreased sounds are indicative was 87%. Measured at 1602 with a
Objective: use of wall oxygen of 95 or higher AEB breathing sounds of numerous problems reading of 100 and measured again administered at 2L via nasal Objective: Consistent O2 and must be evaluated for at 1830 during physical assessment cannula and pale skin color. monitoring throughout the shift further intervention and reading was 97%.
Subjective: pt states " If I don't with documented ranges of 95% PT goal is met. use my oxygen I feel like or higher. 2. Elevate head of bed and 2. Elevation facilitates
I'm suffocating" position PT. respiratory function by gravity 3. Monitor VS and cardiac 3. All vital signs are impacted rhythm. by changes in oxygenation. LTG: By date of discharge PT will continue to maintain O2 saturation of 95% or higher AEB 4.Review risk factors in the 4. To promote prevention Subjective: PT will express environment or management of risk LTG: Due to limited timing little discomfort in breathing effort to promote wellness at location; goal could not be evaluated for 5. Review oxygen conserving 5. To help maintain proper completeness. techniques oxygenation through less eventful breathing efforts
Image Analysis of “Embrace”
“Embrace” imagery dealing with the five senses. Touch; “Wrap your arms around your own body” (Collins, line 2) shows the image of touching your own body and feeling secure.
Objective: use of wall oxygen of 95 or higher AEB breathing sounds of numerous problems reading of 100 and measured again administered at 2L via nasal Objective: Consistent O2 and must be evaluated for at 1830 during physical assessment cannula and pale skin color. monitoring throughout the shift further intervention and reading was 97%.
Subjective: pt states " If I don't with documented ranges of 95% PT goal is met. use my oxygen I feel like or higher. 2. Elevate head of bed and 2. Elevation facilitates
I'm suffocating" position PT. respiratory function by gravity 3. Monitor VS and cardiac 3. All vital signs are impacted rhythm. by changes in oxygenation. LTG: By date of discharge PT will continue to maintain O2 saturation of 95% or higher AEB 4.Review risk factors in the 4. To promote prevention Subjective: PT will express environment or management of risk LTG: Due to limited timing little discomfort in breathing effort to promote wellness at location; goal could not be evaluated for 5. Review oxygen conserving 5. To help maintain proper completeness. techniques oxygenation through less eventful breathing efforts
Image Analysis of “Embrace”
“Embrace” imagery dealing with the five senses. Touch; “Wrap your arms around your own body” (Collins, line 2) shows the image of touching your own body and feeling secure.