Nursing care plan #2 sem 3 PDF

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Summary

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Description

Nursing Care Plan Student(s) Name: Jennah Farnell

Date: March 29, 2021

Patient’s Initials: C

Medical Diagnosis: respiratory failure, HTN

Assessment Data

S: pt complained of pressure in her abdomen. Pt stated, “it hurts when I have to push to have a bm”. Pt’s belly was soft. O: pt is obese and bed bound. She is able to roll side to side in the bed. has abdominal pain that may be associated with the larger foley catheter. Pt is on 02 @ 2L/mins and has normal respirations. Vitals: AM T: 36.9 P: 79 02: 93 R: 18 BP: 157/82 Pt is verbal, A+Ox3. Pt is a full mechanical lift x2 assist into bariatric chair. Pt cannot ambulate on own and is laying on a bariatric air bed.

Nursing Diagnosis and Related Goals

Inadequate gas exchange r/t respiratory failure d/t obesity.

Short Term Goal: Pt will maintain optimal gas exchange as evidenced by usual mental status, unlabored respirations of 12-20 per minute, oximetry results within normal range, blood gases within normal range, and baseline HR for patient.

Long Term Goal: pt will verbalize an understanding of oxygen and other therapeutic interventions.

Nursing Interventions and Rationale Interventions STG: 1. Pt continues oxygen therapy at 2L/min 2. Pt will continue to use CPAP machine at night 3. Monitor for alterations in BP, HR, and respirations

Evaluation

Met: pt is understanding and maintains oxygen therapy via NP @ 2L/min. pt continues to use CPAP machine at night. BP, HR and resp is checked twice a day or prn.

Rational: Continuing the pt on oxygen therapy until they can manage without. Pt will continue to use CPAP machine to ensure adequate breathing during sleep. Monitoring for alterations in BP, HR and resp’s to be away of early signs of hypoxia or hypercapnia. Interventions LTG: 1. auscultate presence of adventitious sounds 2. monitor oxygen saturation using a pulse oximeter 3. pt will keep head of bed elevated about 45 degrees

Met: nurse assess the pt twice daily or prn for lung sounds, and oxygen levels. The pt enjoys having the head of the bed raised and leaves in at about 45 degrees most of the day.

when supine References:

https://nurseslabs.com/impairedgas-exchange/

Rational: A nurse will come in the patient’s room to auscultate lung sounds in the morning and evening. The nurse will also observe the 02 levels at the same time. Pt leaves the head of bed raised to relieve pressure of the chest....