Reference no: EM132400737
CARE PLAN
ASSESSMENT AND PROBLEMS IDENTIFIED
It is acceptable to combine nursing diagnoses if all of the interventions are the same and directed at the problem. For example, impaired spontaneous ventilation, impaired gas exchange and ineffective breathing pattern related to hypoventilation, acid base disturbance, fluid in the lungs secondary to acute respiratory failure, pneumonia as evidenced by pH 6.8, CO2 of 50, pO2 50, respiratory rate of 36, shallow respirations, pulse ox undetectable, non-productive cough, crackles in the lungs, and need for mechanical ventilation.
You can see in the above example that all interventions are targeting the airway and oxygenation.
This also means that medications given to improve gas exchange and oxygenation will also be included in the interventions.
NURSING DIAGNOSIS
*8 Nursing Diagnosis REQUIRED
*Appropriately identified
*Correctly stated
-If an actual problem is identified, choose an -Actual Nursing Diagnosis (4 -parts)
1. Problem
2. Related to (patho)
3. Secondary to (medical diagnosis)
4. As Evidenced By (defining characteristics, presenting signs/symptoms)
-If an actual problem is not identified and a risk for a problem exists please choose a- Risk for Nursing Diagnosis (2-parts)
1. Potential problem
2. Related to (risk factor, etiology)
GOALS
*Client centered
*Measurable
*Realistic
*Time specific parameters
*Related to the Nursing Diagnosis
*Client will...(verb)...(expected outcome/s)...(specific time frame)
INTERVENTIONS-8 Nursing Interventions REQUIRED
*Specific to the client's needs
*Time specific instruction
*Must be related to Nursing Diagnosis/problem identified
*Organized and logical flow with appropriate interventions for the following categories:
ASSESSMENTS-physical findings, defining characteristics
MEDICATIONS-drug, dose, route, frequency, assessments for therapeutic effects/adverse effects, pertinent labs
TREATMENTS-nursing or medical orders to help to resolve the problem such as: dressing changes, triflow, TCDB, ambulation
DIAGNOSTIC STUDIES TO MONITOR
TEACHING- client education, significant other, care giver
Attachment:- Care Plan Template.rar