NUR 171

Supportive Educative Nursing

Comprehensive Nursing Care Plan

Abi Beutler
Name

2/15/15
Date

NUR 171 NURSING CARE PLAN GRADING GUIDELINES

Student name ____________________
Key: S = satisfactory, NI = needs improvement, U = unsatisfactory
6.26.2012

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PEER EVALUATION &

COMMENTS Signature__________

ASSESSMENT
Nursing Data Base is complete and appropriate
to assigned client.
Signs and symptoms of Nursing Diagnoses and
potential Nursing Diagnoses are highlighted in
Data Base.
Preparation for Safe Patient Care packet with
corrections is included.
NURSING DIAGNOSIS
All actual and risk diagnoses, prioritized according to Maslows Hierarchy, are listed.
The first two priority diagnoses are developed
into plans.
At least one diagnosis from your list should be
identified as Supportive/Educative, such as Deficient Knowledge or Ineffective Management of
Therapeutic Regimen, and requires primarily
teaching interventions. Use this diagnosis to
complete the Teaching Plan on p 8/9.
Diagnoses are appropriate to the client: defining
characteristics are identified in assessment.
Diagnoses are correctly written in PES Format.
OBJECTIVES
Objectives begin with Client will and are appropriate to nursing diagnoses.
Objectives are measurable with appropriate
A.E.B. statements.
INTERVENTIONS and RATIONALES
Interventions are specific and individualized,
start with a verb (e.g., teach, turn, cough, monitor) and specify when or how each will be done.
Interventions are nursing functions that are sufficient to accomplish goals. (Could a colleague
implement this plan? It will likely require > 4
interventions.)
Rationales explain why each intervention will be
effective. Evidence based items are identified.
Rationales and teaching interventions are from a
PROFESSIONAL source, and include author and
page number. Med/Surg text preferred. No dictionaries.
Interventions for teaching diagnosis are specific
and include exactly what will be taught. Attach
teaching materials, PMPs, pamphlets, etc. used.
DO NOT use dot.com websites.
EVALUATION

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INSTRUCTOR EVALUATION &

COMMENTS

Each goal is evaluated as met or not met, and

why.
Each action is identified as having worked or not,
and why.
!IF MORE THAN ONE AREA IS UNSATISFACTORY THE NCP WILL BE UNSATISFACTORY

6.26.2012

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Priority Nursing Diagnosis List

Problem

Impaired Gas Exchange

Etiology

r/t altered blood flow to alveoli secondary to lodged embolus

Signs & Symptoms

a.e.b. dyspnea, nasal flaring, restlessness, abnormal breathing

(increased rate and depth)

Problem

Ineffective Tissue Perfusion: Systemic

Etiology

r/t interruption of blood flow to lower extremity secondary to lodged embo-

lus
Signs & Symptoms a.e.b. altered respiratory rate, bronchospasms, dyspnea, nasal flaring
Problem

Acute Pain

Etiology

r/t biological injury, lack of oxygen to cells

Signs & Symptoms

a.e.b. chest pain

Problem

Ineffective Therapeutic Regime Management

Etiology

r/t complexity of therapeutic regime

Signs & Symptoms

a.e.b. poor warfarin management

Problem

Activity Intolerance

Etiology

r/t imbalance between oxygen supply/demand

Signs & Symptoms a.e.b. inability to walk from car to store without becoming short of
breath
Problem

Social Isolation

Etiology

r/t altered state of wellness

Signs & Symptoms

Problem
6.26.2012

a.e.b. withdrawal from friends and social activities

Sedentary Lifestyle
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Etiology

r/t lack of motivation, lack of interest

Signs & Symptoms

a.e.b. daily routine that does not incorporate physical activity,

demonstrates physical deconditioning

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Priority #1 Nursing Care Plan

Nursing
Diagnosis

Expected
Outcomes

Nursing Interventions

Rationale
Evidence-based?

Evaluation of
Interventions

P: Impaired

Client will

Monitor respiratory

Increased respiratory

Met:

Gas Ex-

maintain

rate, depth and effort

rate, use of accessory

Client main-

change

clear lung

including use of ac-

muscles, nasal flaring, tained easy respi-

fields and

cessory muscles,

remain free

nasal flaring, and ab-

of signs and

dominal breathing

the clients eyes may

symptoms

patterns every two

be seen with hypoxia.

of respirato-

hours.

abdominal breathing,

rations without

and a look of panic in the use of acces-

ry distress

(Ackley and Ladwig

by

9th edition p.388)

sory muscles.

2/13/2015.
E: r/t altered

Help the client deep

Controlled coughing

Met:

blood flow

breathe and perform

uses the diaphragmat-

Client was able

to alveoli

controlled coughing

ic muscles, which

to deep breathe

secondary
to lodged

every two hours while make the cough more

awake.

forceful and effective.

embolus

times every two

hours.

(Ackley and Ladwig

9th edition p.389)

6.26.2012

and cough 3

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S: dyspnea,

Teach the client relax-

Relaxation therapy

Met:

nasal flar-

ation techniques (ex.

can help reduce dysp-

Client was able

ing, rest-

progressive muscle

nea and anxiety.

to preform pro-

lessness,

relaxation) to help re-

abnormal

duce stress responses

(Ackley and Ladwig

ation and report-

breathing

and panic attacks

9th edition p.391)

ed feeling less

(increased

from dyspnea.

gressive relax-

anxious.

rate, depth,
PsO2 )
Help the client eat

Improved nutrition

Met:

frequent small meals

can help increase

The client ate 5

and use dietary sup-

muscle aerobic capac-

small meals

plements as necessary. ity and exercise toler-

through the day

ance.

instead of 3 larg-

(Ackley and Ladwig

er meals to en-

9th edition p.389)

sure that she was

getting the proper nutrition.

Evaluation
of expected
outcomes

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Client was
able to
maintain
clear lung
fields and
remained
free of signs
and symptoms of respiratory distress by
2/13/2015

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Priority #2 Nursing Care Plan

Nursing
Diagnosis

Expected
Outcomes

Nursing Interventions

Rationale
Evidence-based?

Evaluation of
Interventions

P: Ineffec-

The client

Elevate edematous leg

Elevation increases

Met:

tive Tissue

will demon- as ordered and ensure

venous return, helps

Clients left leg

Perfusion:

strate effec- no pressure under the

decrease edema, and

was elevated by

can help heal venous

placing a pillow

leg ulcers,

under her lower

Systemic

tive tissue

knee while in bed.

perfusion
a.e.b. PaO2

leg to keep her

levels >90%

(Ackley and Ladwig

heel off of the

on room air,

9th edition p. 846)

bed and to assist

and the ab-

in decreasing the

sence of

edema. Clients

respiratory

edema was stable

distress by

non-pitting and

2/14/15

did not worsen.

Client tolerated it
well, reported no
pain or discomfort.

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E: r/t inter-

If the client is over-

Obesity is a risk fac-

Met:

ruption of

weight, encourage

tor for development

Client stated that

blood flow

weight loss to de-

of chronic venous

she has gained

to lower ex-

crease venous disease.

disease.

weight over the

(Ackley and Ladwig

last couple years

9th edition p. 846)

and no longer

tremity secondary to
lodged em-

exercises. The

bolus

benefits of exercise and weight

loss were discussed and client
was making
plans to start
walking for at
least 20 minutes
a day after discharge.

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S: aeb

Check the brachial,

Diminished or absent

Met:

swelling of

radial, dorsalis pedis,

peripheral pulses in-

Clients brachial,

extremity,

posterior tibial and

dicate arterial insuffi-

radial, dorsalis

cellulitis

popliteal pulses bilat-

ciency with resultant

pedis, posterior

erally every 8 hours.

ischemia.

tibial and

If unable to find them,

(Ackley and Ladwig

popliteal pulses

use a doppler stetho-

9th edition p. 845)

were checked bi-

scope and notify the

laterally and had

physician immediate-

no changes dur-

ly if new onset of

ing her stay.

pulses not present.

Note skin color and

Skin pallor or mot-

Met:

feel the temperature

tling, cool or cold

Client's skin re-

of the skin every eight

skin temperature, or

mained pink,

hours.

absent pulse can sig-

warm and intact

nal arterial obstruc-

through stay. No

tion, which is an

changes in tem-

emergency that re-

perature or color.

quires immediate intervention.

(Ackley and Ladwig
9th edition p. 845)
Evaluation
of expected
outcomes

6.26.2012

11
!

Met: Client

Educate about

maintained

coumadin

PaO2 of
94% on
room air.
Client maintained respirations that
were a regular rate,
rhythm and
depth, and
did not require the
use of accessory
muscles,
with no
nasal flaring.

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TEACHING PLAN
Teaching Topic
Warfarin Management, Pulmonary Embolism
Clients Current Understanding of Topic
I didnt think I had blood clotting issues any more because the doctor stopped my
coumadin after my fall. I know when you take coumadin that you have to watch some
of the things that you eat.
Clients Learning Style
Auditory, Visual
Clients Readiness to Learn
Client is engaged in learning about her illness and the warfarin that is used
to help prevent the blood clots from forming.
Teaching Methods Used
Medication informational sheets, hand drawn picture of basic blood circulation.
Content Taught (provide content outline or attach content from reliable source)
Warfarin information sheet printed from micromedex
coumadin.com list of foods high in Vitamin K

Evalulation of Learning
Client was receptive to the information. She did not realize how many foods had
Vitamin K in them or that she could eat foods that contained it as long as she ate the same
portion every day to keep the vitamin K levels the same.
She understand that warfarin increases your bleeding time but did not realize that
she should not use a regular razor when shaving. She knew that the warfarin contributed
to her brain bleed after her fall but hadnt put much thought into being cautious of falling
6.26.2012

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prior to that incident.

She stated that she had regular appointments to have her PT/INR drawn in the past
and that she understood that it was those test results that the doctor used to dose her warfarin.
Client stated that she was told with her first blood DVT in 1999 that if she were to
get a blood clot again in would most likely also be in her leg. She was confused as to why
she had them in her lungs if she was supposed to get them in her legs. After drawing a basic model of how the blood circulates through the body she was able to understand that
the clots in her lungs most likely formed in her legs and then moved through her body to
her heart and over to her lungs where they became lodged. Client expressed thanks and
stated that she appreciated the time spent to explain how she got her PE.

Resources:
http://www.jblearning.com/samples/0763751375/46436_CH05_000_000.pdf
Ackley and Ladwig: Nursing Diagnosis Handbook. Mosby
Readiness for enhanced knowledge
Deficient knowledge
Ineffective health maintenance
Ineffective therapeutic regimen management
Fundamentals of Nursing textbook

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