Example of Nursing Care Plan using Nursing Process for sample case study given in NUR 3825

Color coded – red = problem; blue = etiology; green = relationship between problem and etiology

Step 1 Management
-Assessment Planning
Ineffective Step 4 - Step 5 - (part of step 5) Step 6 - Step 7 -
Nursing
airway Client Outcomes/ Nursing Rationale Evaluation of Client Outcomes (Goals)
Implementation
clearance Interventions & Reference s
R/T
Expected
decreased Outcomes
hydration
secondary to
URI
S – “I cough Etiology Outcomes During the CNC visit today, the nurse Etiology
& cough but (Given appropriate will: At the end of 24 hours the nurse will call Mr. SJ to determine
Implemented as
can’t seem to A. Encourage Mr. SJ to A. Increased planned. the results of the etiology outcomes.
bring much
nursing drink 100 ml fluid 1. Achieved – Client states his skin returns to
fluids
up.” interventions are every hour while between resting state when released.
implemented,) Mr. awake. Instruct him 2000-3000 2. Client states he drank four 8 oz glasses of
S – “I haven’t SJ will have that he needs to ml/24 hr water, two 8 oz glasses of orange juice,
been drinking increased hydration have 2000-3000 will help to three 8 oz glasses of lemonade, and
much lately.” ml/24 hr. of non- rehydrate two 6 oz cups of decaffeinated coffee.
within 24 hours caffeinated fluids, Total fluid intake = 2520 ml
clients L &
O – Coughs AEB (as evidenced such as apple juice S, 1996, 3. Achieved. Client states he has urinated
5-10 times in by): or water. 1105. five times for 500 ml each time.
ten minutes. 1. skin B. Ask Mr. SJ to use a Caffeinated. Summary: The outcomes, as a whole, are achieved.
Two ml thick immediately humidifier at the . The diagnosis is continuing and the client will be seen
white mucus bedside during the beverages tomorrow in the clinic in order to evaluate the ineffective
obtained.
returning to time he is in bed. breathing. No changes needed at this time.
should be
resting state limited or Client is adhering to requests.
O – Rhonchi when avoided Evaluate client tomorrow on return to clinic.
auscultated in released C. Encourage client to completely,
right upper 2. Fluid intake deep breath and since they act Problem:
lobe. Other cough every two as diuretics At the end of 48 hours Mr. SJ returns to the clinica
of 2000 –
lung fields hours while awake. and can for evaluation of his problem outcomes.
clear. 3000 ml/24 D. Others. 1. Partially achieved. Coughing productively, but
contribute to
hr non- dehydration. P the mucus is thicker and greenish-yellow in color.
O – RR = 28 caffeinated & P, 2001, 2. Not achieved. Lung sounds are bilaterally
with minimal fluids (by 1161. diminished with occasional rhonchi auscultated
accessory in right upper lobe.
client
muscle use. B. Air… with Implemented as 3. Not achieved. RR = 28 with accessory muscle use.
report) planned. 4. Not achieved. Skin color pale.
a high
O –Skin color 3. Urine output relative 5. Not achieved. Client states
pale. Poor of 1400 – humidity “I am having more trouble breathing and feel worse.”
skin tugor = 1800 ml/24 keeps the Summary – The outcomes, as a whole, are not achieved.
pinched skin hr (by client airways The client’s condition has worsened.
takes 10 report) moist and The diagnosis as stated needs modification to include
seconds to 4. others??? helps his worsening respiratory status. The outcomes for the
return to loosen and problem continue to be appropriate. Additional
resting state. mobilize interventions need to be implemented, including
Problem respiratory contacting his physician for an immediate appointment.
O – Hct = Outcomes secretions. A sputum specimen needs to be obtained for C & S.
54% (Normal Given that the P & P, The client needs to be evaluated on a daily basis at this
Hct males = client has increased 2001, 1162 time. WHAT ELSE?????
42-52%) C. Coughing Not implemented
hydration, Mr. SJ permits the as planned. The
will have effective client left the
O – voided client to CNC before this
200 ml dark airway clearance remove could be done.
yellow urine within two days secretions The nurse will
call the client at
S.G. = 1.07 AEB: from both home and discuss
(N = 1.010- the upper this with him.
1.025)
1. Coughing and lower
productively airways. P
S – 24 hour of 3-5 ml & P, 2001,
fluid recall moderately 1162.
0600- 1 cup thin clear D. S.R. would
caffeinated be needed.
mucus
coffee
1100- 1 12 within three
oz. to five
caffeinated coughs.
coke 2. Breath
1400 – 1 12
sounds
oz
caffeinated bilaterally
coke clear and
1700 – 1 equal in all
cup lung fields
caffeinated A & P.
coffee
3. RR = 12-24
O – fluid without
analysis = 40 accessory
oz. (1200 ml) muscle use.
caffeinated 4. Skin color
fluids/24 hr
(N = average pink
adult oral 5. Client states
intake = “I am
1100- breathing
1400ml/24 better now
hr.)
and
coughing
O= mucus up.”
“Maintenance 6. Others
of adequate
systemis
hydration
keeps
mucocilliary
clearance
normal.” (P
& P, 2001 p.
1162)