Student Name: Lisa Chee

Date: 11/18/2014-11/19/2014
N256 Mini Care Plan- Patient B

Nursing
Diagnoses
(NANDA)

Focus of physical
assessment

Expected
(complete before assessment)

Found
(complete after assessment)

1. Ineffective breathing pattern r/t pneumonia and

1. SAME
2. Constipation r/t inactivity AEB pt reports abdominal
discomfort and states "I haven't had a BM in two days"
3. SAME

COPD AEB dyspnea and SOB

2. Noncompliance r/t health beliefs AEB behavior

indicative of failure to adhere to a therapeutic
recommendation
3. Risk for infection r/t peripheral IV access
Focused respiratory assessment, assess IV sites for
infiltration/phlebitis, monitor VS for s/s infection,
monitor for therapeutic treatment compliance

Breathing better or worse upon admission? What activities

triggers SOB? How long does it take pt to recover from
episodes of SOB?

Need more
information
from
patient/family/
doctor about:

Top three
priorities (goals)
for patient care

Nursing
Interventions

Teaching
needed/provided

Discharge
planning

SAME

1. Pt maintains an effective breathing pattern, AEB

relaxed breathing at normal rate and depth, and
absence of dyspnea, cyanosis, or use of accessory
muscles.
2. Pt reports compliance with therapeutic plan.
3. Pt is free from s/s infection AEB healing wound,
incision clean/dry/intact, well approximated, no
redness or purulent drainage, clear breath sounds
w/o cough/sputum.
1. Conduct a focused respiratory assessment (RR,
and absence of dyspnea, cyanosis, or use of
accessory muscles)
2. Educate pt to elevate HOB to help facilitate easier
breathing. Encourage pt to use incentive spirometer.
Provide ordered O2 therapy.
3. Assess the patients individual perceptions of
health problems. Assess beliefs about current illness
and treatment plan. Assess factors the patient feels
interfere with compliance.
4. Develop a therapeutic relationship with the patient
and family. Include patient in planning the treatment
regimen. Tailor the therapy to the patients lifestyle
and culture.
5. Assess surgical site for redness, swelling, warmth,
pain.
6. Maintain asespsis and proper hand hygiene.
Administer ABX as prescribed.
Dressing changes if necessary, educate pt on s/s
infection, proper hand hygiene, infection prevention,
SE of prescribed medications. Pt education for
therapeutic treatment

1. SAME
2. Pt passes soft, formed stool at a frequency perceived as
normal by the pt
3. SAME

Home, medication instructions, follow up

instructions w/ PCP

SAME, plus if pt is discharged home w/ O2 therapy, provide pt

education of home O2 therapy (no smoking, away from heat
source). Follow up with respiratory therapist.

1. SAME
2. SAME
3. Assess usual pattern of elimination; compare with
present pattern. Include size, frequency, color and quality
of stool. Assess activity level and evaluate current
medication usage that may contribute to constipation.
4. Encourage pt to increase fluid and fiber intake.
Encourage pt to ambulate in hallway. Administer Miralax.
5. SAME
6. SAME

No dressing changes needed, everything else same. Educate pt

on avoiding irritants that trigger SOB, smoking cessation