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Inessa Borovskiy 1

NURSING CARE PLAN

STUDENT’S NAME: Inessa Borovskiy CLINICAL INSTRUCTOR:

DATE OF PATIENT CARE:

DEMOGRAPHIC DATA:

Patient Assignment #: _______ Age: 77 Gender: Male Date of Admission 9/21/2018 Advance Directives Full Code

(Indicate if DNR/DNI or Full Code)

HISTORY OF PRESENT ILLNESS:

REASON FOR SEEKING HEALTHCARE (“What brought you to the hospital?” – must include “What happened, where, when, how

long PTA”): Patient stated that he came to the hospital because he, “couldn’t breathe.” The patient reported that he was at home when he

became short of breath.

ADMITTING MEDICAL DIAGNOSIS (DIAGNOSES): COPD Exacerbation

ALLERGIES: No known drug allergies REACTION: N/A

I. PAST MEDICAL HISTORY (Include date condition was diagnosed, if known): Hypertension, hypercholesterolemia, chronic

obstructive pulmonary disease (COPD), enlarged prostate, diabetes mellitus, atrial fibrillation, congestive heart failure (CHF), arrhythmia,

sleep apnea, retained metal fragment

II. PAST PSYCHIATRIC HISTORY:


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Describe & include history of treatment: No known past psychiatric history

Current Mood: [ ] Depressed [X] Anxious [ ] Withdrawn

Communication: [X] Verbal [ ] Non-verbal [ ] Cues/behaviors (specify) _________________________________

Other: The patient appeared anxious and verbalized multiple times that he wanted to go home.

III. PAST SURGICAL HISTORY (Include dates of surgery, if known): Bronchoscopy with endobronchial ultrasound (9/10/2018)

IV. PSYCHOSOCIAL HISTORY:

Spiritual/ Cultural Assessment: Religion Catholic Cultural/ethnic background White Marital status Married

Smoking: [X] Yes (Specify # cigarettes/packs per day 40 cigarettes/2 packs per day for 58 years) [ ] No

Smoking Cessation Teaching: [X] Yes [ ] No

Substance Abuse: [ ] Yes (Specify Substance ___________________________ Treatment ________________) [X] No history

V. VACCINE HISTORY:

Influenza Vaccination – [ ] Yes (Date: _______) [X] No Pneumovax [X] Yes (Date: Unknown) [ ] No

If No, Specify Reason Patient has an order for an influenza vaccine. He is expected to receive the influenza vaccine before discharge.

Other: The patient stated that he received a Pneumovax vaccine but was not able to recall the date the vaccine was administered.

VI. LAB VALUES (Include Date of Results, Specific Value with Unit of Measure, & if High or Low)

Hemoglobin – 9/24/18, 8.3 g/dL, Low Na – 9/24/18, 134 mEq/L, Low BUN – 9/24/18, 21 mg/dL

Hematocrit – 9/24/18, 27.1%, Low K – 9/24/18, 4.7 mEq/L Creatinine – 9/24/18, 1.40 mg/dL, High
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WBC – 9/24/18, 10.3 cells/mL, High CO2 – 9/24/18, 28 mEq/L Glucose – 9/25/18, 120 mg/dL, High

Platelets – 9/24/18, 373 platelets/uL CL – 9/24/18, 96 mEq/L, Low Albumin – 9/21/18, 3.7 g/dL

PT – 9/21/18, 19.8 seconds, High INR – 9/21/18, 1.8, High aPTT – 9/21/18, 39.6 seconds, High

VII. VITAL SIGNS and PAIN ASSESSMENT

BP 120/55 mmHg (Left arm, sitting) Radial (rate/rhythm) 99 bpm RR 20 breaths/min Temp. 36.7°C (98.1ºF) Pulse Oximetry 90%

Height 5 ft 7 inch (170.18 cm) Weight 156 lb (70.8 kg) BMI 24.43 kg/m2 Indicate if: [X] Normal [ ] Overweight [ ] Obese

[ ] Underweight

Time Location of Pain Scale (Pre) Interventions Scale (Post) Comments

During my shift on 9/25/2018 from 8 AM to 3:30 PM, the patient denied having any pain.

VIII. INTAKE & OUTPUT (During your shift – indicate amount in ml.):

INTAKE OUTPUT

Type Amount Type Amount

P.O. (water, juice, soup, meds) 240 mL URINE 2X (unmeasured)

INTRAVENOUS (IV) OSTOMY

FEEDING DRAINAGE

OTHER (specify) OTHER (specify)


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TOTAL 240 mL TOTAL + 240 mL

IX. PERIPHERAL & CENTRAL INTRAVENOUS LINES

Type Peripheral IV (Single Lumen) Date Inserted 09/22/2018 Site Basilic vein (medial side of right arm)

Describe Site Appearance Bruised (ecchymotic), flaky and dry

X. PHYSICAL ASSESSMENT / SYSTEMS REVIEW

1. Neurological System:

Subjective Data: The patient denied having a headache or any changes in his vision or hearing.

LOC: [X] Alert [ ] Confused [ ] Lethargic [ ] Restless [ ] Aphasic Orientation: [X] Time [X] Place [X] Person

Pupils: [X] Equal [ ] Unequal [X] Brisk [X] Sluggish [ ] Nonreactive [ ] Irregular [ ] Opaque Aids: [ ] Glasses [ ] Hearing Aid

Other: The patient was alert and oriented to person, place, time, and situation. Movement RA 4, RL 5, LA 4, LL 5. The total Glasgow

Coma Scale score was 15 with a score of 4 for eye-opening indicating that the patient opens his eyes spontaneously, for motor response

the patient scored a 6 suggesting that the patient obeys simple commands, and the patient scored a 5 on the verbal response indicating that

the patient is oriented x 3 to person, time, and place.

Describe abnormal findings: Right pupil size 2 mm with sluggish response to bright light and left pupil size 2 mm with brisk reaction to

bright light.

2. Neuromuscular System:

Subjective Data The patient reported bilateral tremors in his upper extremities.
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Motor & Sensory Function: [X] Intact Weakness: [X] Right [X] Left Paralysis: [ ] Right [ ] Left

Gait: [X] Steady [ ] Unsteady Use of Assistive device: [ ] Cane [ ] Walker [ ] Wheelchair

Other: The patient does not use an assistive device. The patient was able to maintain flexion against resistance. The patient was able to

extend his arms and move his them against resistance along with flexing his arms against resistance with a grade of 5. The patient’s

right-hand grip was 4 out of 5, and his left-hand grip was 3 out of 5. No joint crepitation or deformities were evident.

Describe abnormal findings: Tremors in the upper extremities particularly in the patient’s hands were evident. When asked the patient to

shrug his shoulders, there was evidence of weakness in his left shoulder compared to his right shoulder.

3. Cardiovascular:

Subjective Data: The patient denied any chest pain or palpitations.

[ ] Chest Pain (Describe) N/A [ ] Palpitations (Describe) N/A

Peripheral Pulses (Specify 0 – 3+): Radial: [3+] Right [3+] Left

Other: Palpable distal pulses on all extremities. No upper extremity edema.

Describe abnormal findings: Unable to palpate patients dorsalis pedis pulses bilaterally. Capillary refill less than 2 seconds bilaterally on

the upper and lower extremities. Edema of +1 noted on the right lower extremity. On 09/22/2018, the patient had an EKG-12 lead placed

showing an abnormal ECG with ventricular 86 BPM, atrial 394, QRS duration 74 ms, and Q-T interval 348 ms.

4. Respiratory:

Subjective Data: The patient denied shortness of breath when moving from bed to chair and patient denied chest pain.

RR 20 breaths/min Pattern: [X] Regular [ ] Irregular [ ] Use of accessory muscles


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[ ] Breath sounds clear, bilateral [ ] Rhonchi- right [ ] left [X] Wheezing – right [ X] left [X] [ ] Crackles – right [ ] left [ ]

[X] O2 therapy (specify) 90% on room air. Oxygen via device to keep O2 saturation continuous between 88% to 95%.

[X] Cough – productive - No [X] Yes [ ] Describe Non-productive cough observed. Sputum induction performed once with minimum

sputum collected.

[ ] SOB at Rest [X] SOB On Exertion Other: Wheezing heard bilaterally. The patient’s respirations were regular and even with no

use of accessory muscles. The patient was educated on the use of an incentive spirometer and recommended to use the incentive

spirometer 10 times per hour.

5. Gastrointestinal:

Subjective Data: The patient denied any changes in his bowel movement, nausea, vomiting, diarrhea, constipation or pain. The patient

stated he ate all of his breakfast which consisted of oatmeal and juice. However, the patient also reported having a decreased appetite

because he did not like the hospital food.

Abdomen: [X] Soft [ ] Firm [ ] Distended [ ] Tenderness [X] Bowel sounds: [X] Present [ ] Diminished [ ] Absent

[ ] Nausea [ ] Vomiting N/A [ ] Anorexia [ ] NGT to suction [ ] Last BM (Date) 09/24/2018 [ ] Constipation

[ ] Diarrhea # times N/A Type of Stool Soft Onset________ [ ] Ostomy (specify) N/A

Dental/Oral Health (describe) Mucosa and gingivae intact, dry, pink with no presence of lesions or bleeding. Teeth intact, good dentition.

Tongue symmetric protrudes midline. NGT/OGT/PEG feeding N/A

Gastric Residuals (color/Amount) Brown/amount not recorded


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Other: The patient’s abdomen was round, asymmetrical, soft, nontender, and protruding to the right. Normoactive bowel sounds in all

four quadrants. A Hematoma was evident on the right lower quadrant. The skin around the hematoma was intact with no presence of

redness or discoloration. The patient denied any pain around the area. The patient was on a diabetic diet consistent carbohydrate standard

(60 grams).

6. Genitourinary:

Subjective Data: The patient denied dysuria, frequency, urgency, nocturia, hesitancy, or straining while urinating.

Urine Color Yellow Character Clear [X] Voiding [ ] Foley catheter – date inserted N/A

[ ] Incontinence [ ] Dysuria [ ] Hematuria [ ] Hemodialysis (frequency) N/A Last Dialysis N/A

Dialysis Access: [ ] AV Shunt [ ] AV Graft [ ] Permacath/Cook’s Catheter Describe Site: N/A

Thrill: N/A Bruit: N/A Other: The patient is continent and is voiding in the toilet. His urine color is yellow and clear with no presence

of blood or any abnormalities in the urine.

7. Integumentary:

Subjective Data: The patient stated he developed bruises on his upper extremities following insertion of a peripheral IV (PIV) line first on

the left upper extremity followed by the insertion of a PIV line on his right upper extremity.

Skin quality: Temperature [ ] Cool [X] Warm [X] Dry [ ] Moist [X] Ecchymosis [ ] Hematoma [X] Petechiae

[X] Edema (indicate location) 1+ Right Lower Extremity [ ] Rash [ ] Scar N/A

[ ] Pressure ulcer site No evidence of a pressure ulcer

Braden Scale Score 21 [ ] Operative wound (describe) N/A


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Other: The patient’s overall skin was intact and appropriate for ethnicity with no evidence of rashes, pruritis, jaundice, or cyanosis.

Ecchymosis was present on his upper extremities bilaterally.

Students need to submit a written summary of the following assessment tool findings and interpretation with the NCP.

(The NCP must be uploaded as ONE electronic Word document labeled with your last name & assignment name, e.g., Jones NCP):

1. Braden Scale Total Score 21, the patient is not at risk for developing a pressure ulcer. The patient’s sensory perception, ability

to respond to pressure-related discomfort, was 4 indicating no impairment. W.V’s moisture score was 4 signifying he responds

to verbal commands and has no sensory deficit which would limit his ability to feel or voice pain or discomfort. W.V’s activity

score was 3. He can walk without the use of an assistive device such as a walker but for very short distances due to the

development of shortness of breath. Therefore, W.V spent the majority of my shift in a chair. The patient’s mobility score was a

3. W.V has slight limitations when changing his body position. However, the tremors he exhibits in his upper extremities

bilaterally limit his ability to change positions. W.V’s nutrition intake score was a 4, excellent. He ate all of his breakfast and

more than 90% of his lunch. W.V scored a 3 on the friction and shear portion of the assessment. He can move in his chair

independently and has sufficient muscle strength to lift completely. W.V maintains good position while sitting in the chair.

(Ayello, 2017).

2. Hendrich II Fall Risk Assessment Total Score 5, the patient is at high risk for falls. The patient’s score consisted of one point

for dizziness and vertigo and one point for the male gender portion of the assessment. He scored a 3 on the “Get Up & Go

Test.” W.V was unable to rise in a single movement, however, after multiple attempts, he was able to successfully get out of the

chair and walk for a short distance. (Hendrich, 2016).


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3. Katz Index of Independence in Activities of Daily Living Total Score 6, the patient can perform activities of daily living such as

bathing, dressing, toileting, transferring, continence, and feeding independently. The patient can bathe himself thoroughly.

However, he may require assistance when washing a particular area such as his back or genital area. W.V can get his clothes

from the closet or drawers and put the clothes on without the need of assistance. The patient goes to the toilet, gets on and off,

and cleans his genital area without support. He can move in and out of bed or chair unassisted, however, may require the use of

an assistive device such as a walker when walking long distances. W.V is continent having complete self-control over urination

and defecation. The patient can feed himself including getting food from the plate and into his mouth without help. (Wallace &

Shelkey, 2007).

XI. MEDICATIONS (use another sheet or add rows to table if needed)

Medication (as ordered by Reason For Taking Them? Side Effects, Contraindications Patient and Family Teaching
M.D. /NP) – Classification – (Example: To treat Hypertension and Lab Values to be monitored (Only specific instruction for that drug)
How does the medication work and CHF) (Only specific, priority ones) Never write: Take as directed
(Chemical action)? Cite references here
& in reference list in APA format.

Atorvastatin (LIPITOR) Tablet 10 To treat hypercholesterolemia Side Effects: Headache, myalgia, Educate the patient to follow a
mg, Oral, Daily (Hodgson, Kizior, 2016, p. rash, pruritus, and allergy special diet and avoid excessive
102). (Hodgson, Kizior, 2016, p. 103). alcohol intake and large quantities
Classification: Contraindications: Active of grapefruit products. (Hodgson,
Antihyperlipidemic (Hodgson, hepatic disease, unexplained Kizior, 2016, p. 103).
Kizior, 2016, p. 102). elevated liver function test (LFT)
results. (Hodgson, Kizior, 2016, Teach the patient about proper
Chemical Action: Inhibits the p. 102). intake of the medication such as
enzyme HMG-CoA reductase, instructing the patient not to chew,
which catalyzes one of the first Lab Values: crush, dissolve, or divide tablets.
steps in cholesterol synthesis. Monitor cholesterol, triglyceride, (Hodgson, Kizior, 2016, p. 103).
(Hodgson, Kizior, 2016, p. 102). hepatic function tests, and
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Medication (as ordered by Reason For Taking Them? Side Effects, Contraindications Patient and Family Teaching
M.D. /NP) – Classification – (Example: To treat Hypertension and Lab Values to be monitored (Only specific instruction for that drug)
How does the medication work and CHF) (Only specific, priority ones) Never write: Take as directed
(Chemical action)? Cite references here
& in reference list in APA format.

creatine phosphokinase (CPK). Educate patient on signs and


(Hodgson, Kizior, 2016, p. 103). symptoms to report to his
healthcare provider including dark
urine, muscle fatigue, and bone
pain. (Hodgson, Kizior, 2016, p.
103).

Diltiazem (CARDIZEM CD) To treat Hypertension Side Effects: Peripheral edema, Educate the patient against abrupt
Capsule 360 mg, Oral, Daily (Hodgson, Kizior, 2016, p. dizziness, light-headedness, discontinuation of the medication
369). headache, bradycardia, and (Hodgson, Kizior, 2016, p. 371).
Classification: asthenia. (Hodgson, Kizior,
Calcium channel blocker; 2016, p. 371). Instruct the patient to slowly rise
antihypertensive (Hodgson, Kizior, from lying to a standing position
2016, p. 369). Contraindications: Acute MI, to avoid hypotensive effects.
pulmonary congestion, (Hodgson, Kizior, 2016, p. 371).
Chemical Action: Inhibits calcium hypersensitivity to diltiazem or
movement across cardiac, vascular other calcium channel blockers, Educate the patient to report
smooth muscle cell membranes second or third-degree AV block palpitations, shortness of breath,
causing dilation of coronary (except in the presence of pronounced dizziness, nausea, and
arteries, peripheral arteries, and pacemaker), severe hypotension constipation to his healthcare
arterioles. (Hodgson, Kizior, 2016, (less than 90 mm HG, systolic), provider. Additionally, inform the
p. 369). and sick sinus syndrome. patient to avoid alcohol as this
(Hodgson, Kizior, 2016, p. 369). may increase the risk of
hypotension or vasodilation
Lab Values: Assess baseline and (Hodgson, Kizior, 2016, p. 371).
monitor renal and hepatic
function tests. (Hodgson, Kizior,
2016, p. 371).

Ipratropium (ATROVENT) 0.02% Maintenance treatment of Side Effects: Cough, dry mouth, Instruct the patient to increase his
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Medication (as ordered by Reason For Taking Them? Side Effects, Contraindications Patient and Family Teaching
M.D. /NP) – Classification – (Example: To treat Hypertension and Lab Values to be monitored (Only specific instruction for that drug)
How does the medication work and CHF) (Only specific, priority ones) Never write: Take as directed
(Chemical action)? Cite references here
& in reference list in APA format.

Nebulizer solution 0.5 mg, bronchospasm due to COPD. headache, nausea, dizziness, and fluid intake as this decrease’s lung
Nebulization, 4 times Daily (Hodgson, Kizior, 2016, p. transient increased secretion viscosity. (Hodgson,
650). bronchospasm (Hodgson, Kizior, Kizior, 2016, p. 652).
Classification: 2016, p. 651).
Anticholinergic; Bronchodilator Educate patient on proper use of
(Hodgson, Kizior, 2016, p. 650). Contraindications: nebulizer including not to take
Hypersensitivity to atropine. more than 2 inhalations at any one
Chemical Action: Blocks (Hodgson, Kizior, 2016, p. 650). time as excessive use can produce
acetylcholine at parasympathetic paradoxical bronchoconstriction
sites in the bronchial smooth Lab Values: Monitor ABGs and decrease the bronchodilating
muscle. (Hodgson, Kizior, 2016, p. (Hodgson, Kizior, 2016, p. 652). effect. Instruct patient to rinse his
650). mouth with water immediately
after inhalation to prevent mouth
and throat dryness. (Hodgson,
Kizior, 2016, p. 652).

Teach the patient to avoid


excessive use of caffeine products
such as chocolate, coffee, tea,
cola, and cocoa. (Hodgson,
Kizior, 2016, p. 652).

Prednisone (DELTASONE) Tablet To treat chronic obstructive Side Effects: Nausea, diarrhea, Teach patient to take this
40 mg, Oral, Q24h pulmonary disease abdominal distention, increased medication with food or milk to
exacerbation (Micromedex, appetite, sweating, headache, reduce gastrointestinal upset. The
Classification: 2018). depression, flushing, mood patient should avoid drinking
Glucocorticoid (Kee, Hayes, changes, and cataracts (Kee, alcohol and cigarette smoking,
McCuistion, 2015, p. 753). Hayes, McCuistion, 2015, p. due to the increased risk of
753). osteoporosis. (Micromedex,
Chemical Action: Inhibits the 2018).
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Medication (as ordered by Reason For Taking Them? Side Effects, Contraindications Patient and Family Teaching
M.D. /NP) – Classification – (Example: To treat Hypertension and Lab Values to be monitored (Only specific instruction for that drug)
How does the medication work and CHF) (Only specific, priority ones) Never write: Take as directed
(Chemical action)? Cite references here
& in reference list in APA format.

accumulation of inflammatory Contraindications:


cells at the inflammation sites, Hypersensitivity, psychosis, Educate patient to speak to his
phagocytosis, lysosomal enzyme fungal infection, peptic ulcer healthcare provider before
release or synthesis, and release of disease (Kee, Hayes, receiving vaccines due to drug-
mediators of inflammation. McCuistion, 2015, p. 753). induced immunosuppression. The
(Hodgson, Kizior, 2016, p. 1015). patient should avoid exposure to
Lab Values: chicken pox or measles.
Monitor serum electrolytes, (Micromedex, 2018).
blood glucose, hypothalamic-
pituitary-adrenal (HPA) axis Instruct patient to report fever,
suppression tests, urinalysis, sore throat, muscle aches, sudden
chest x-ray, and daily weight weight gain, swelling, loss of
(Micromedex, 2018). appetite, or fatigue to his
healthcare provider. (Hodgson,
Kizior, 2016, p. 1016).

Advise patient to report problems


with glycemic control dye to drug-
induced hyperglycemia due to
diabetes. (Micromedex, 2018).

Teach patient against abrupt


discontinuation of the medication.
(Micromedex, 2018).

Pregabalin (LYRICA) Capsule 50 To treat diabetic peripheral Side Effects: Dizziness, Educate patient to avoid activities
mg, Oral, 2 times Daily neuropathy pain. (Hodgson, drowsiness, ataxia, peripheral that require mental alertness or
Kizior, 2016, p. 1017). edema, weight gain, blurred coordination until his reaction to
Classification: Anticonvulsant, vision, diplopia, difficulty with the medication has been
antineuralgic, analgesic concentration, tremor, and dry established as this medication
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Medication (as ordered by Reason For Taking Them? Side Effects, Contraindications Patient and Family Teaching
M.D. /NP) – Classification – (Example: To treat Hypertension and Lab Values to be monitored (Only specific instruction for that drug)
How does the medication work and CHF) (Only specific, priority ones) Never write: Take as directed
(Chemical action)? Cite references here
& in reference list in APA format.

(Hodgson, Kizior, 2016, p. 1016). mouth. (Hodgson, Kizior, 2016, causes dizziness, blurred vision,
p. 1018). and somnolence. (Micromedex,
Chemical Action: Binds to 2018).
calcium channel sites in the central Contraindications:
nervous system tissue inhibiting Hypersensitivity to pregabalin or Advise patient to report
excitatory neurotransmitter release. any of the components within the unexplained muscle pain,
(Hodgson, Kizior, 2016, p. 1017). product. (Micromedex, 2018). tenderness, or weakness,
particularly if accompanied by
Lab Values: No specific lab malaise or fever. Instruct patient
values to be monitored. Assess to report any changes in his
pain level onset, type, location, vision. (Micromedex, 2018).
and duration of pain. Assess for
peripheral edema particularly Educate patient on the importance
behind medial malleolus, assess of avoiding alcohol while taking
for changes in visual acuity. this medication. (Hodgson,
(Hodgson, Kizior, 2016, p. Kizior, 2016, p. 1018).
1018).

XII. NURSING CARE PLAN

Nursing Diagnosis Short- & Long-Term Interventions Rationale Evaluation


(List 3-5 priority nursing Goals (Must complete in (Evidenced based rationale for (How did/will you evaluate the
diagnoses in order of priority.) (Must complete for EACH comprehensive manner for two each intervention for two highest effectiveness of planned
priority nursing diagnosis listed. highest priority nursing priority nursing diagnoses. interventions listed in previous
Goals should be SMART: diagnoses. Include collaborative Describe in your own words with column? HINT: Assess
specific, measurable, attainable, /interdisciplinary.) references cited here & in attainment of SMART goals.)
realistic, & time-framed.) reference list in APA format.)

Ineffective airway By the end of the shift, Educate and assist the Deep breathing and The patient has been
clearance related to patient will maintain clear patient with deep breathing, controlled coughing maintaining clear airways
Inessa Borovskiy 14
Nursing Diagnosis Short- & Long-Term Interventions Rationale Evaluation
(List 3-5 priority nursing Goals (Must complete in (Evidenced based rationale for (How did/will you evaluate the
diagnoses in order of priority.) (Must complete for EACH comprehensive manner for two each intervention for two highest effectiveness of planned
priority nursing diagnosis listed. highest priority nursing priority nursing diagnoses. interventions listed in previous
Goals should be SMART: diagnoses. Include collaborative Describe in your own words with column? HINT: Assess
specific, measurable, attainable, /interdisciplinary.) references cited here & in attainment of SMART goals.)
realistic, & time-framed.) reference list in APA format.)

retained secretions as airways by effectively performing controlled exercises enable the patient by removing excessive
evidenced by wheezing removing excessive coughing, using the forced to use diaphragmatic secretions through the use
bilaterally and persistent secretions. expiratory technique called muscles creating a more of an incentive spirometer
cough without sputum “huff cough”, and using an effective and productive ten times every hour, deep
production. (Ackley, Within a week, the patient incentive spirometer. cough. Using an incentive breathing, controlled
Ladwig, & Makic, 2017, p. will verbalize and Instruct the patient to spirometer increases coughing, and “huff cough”
131). demonstrate techniques to inhale deeply, hold his inspiratory capacity and methods.
improve airway clearance breath for a few seconds, promotes airway clearance.
such as coughing and cough two or three (Ackley, Ladwig, & Makic, The patient verbalizes and
effectively and maintaining times while keeping his 2017, p. 132; Perry, Potter, conclusively demonstrates
a patent airway. mouth open and tightening & Ostendorf, 2014, p. 599). techniques that improve his
his upper abdominal The forced expiratory airway clearance and help
muscles. technique is known as the maintain a patent airway by
“huff cough” prevents the the removal of excessive
Assist the patient to an closing of the glottis while secretions.
upright position with the the patient is coughing and
head of the bed elevated 30 efficiently clears secretions.
to 45 degrees, shoulders (Ackley, Ladwig, & Makic,
relaxed, and knees flexed 2017, p. 132).
allowing for adequate chest
expansion optimizing An upright position allows
respiration. for maximal lung
expansion while lying flat
causes the abdominal
organs to shift toward the
chest crowding the lungs
making it difficult for the
patient to breathe. Ackley,
Ladwig, & Makic, 2017, p.
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Nursing Diagnosis Short- & Long-Term Interventions Rationale Evaluation
(List 3-5 priority nursing Goals (Must complete in (Evidenced based rationale for (How did/will you evaluate the
diagnoses in order of priority.) (Must complete for EACH comprehensive manner for two each intervention for two highest effectiveness of planned
priority nursing diagnosis listed. highest priority nursing priority nursing diagnoses. interventions listed in previous
Goals should be SMART: diagnoses. Include collaborative Describe in your own words with column? HINT: Assess
specific, measurable, attainable, /interdisciplinary.) references cited here & in attainment of SMART goals.)
realistic, & time-framed.) reference list in APA format.)

131).

Deficient knowledge By the end of the shift, the Use client-centered A systematic review of 38 The patient describes the
related to insufficient patient will describe the methods when educating trials in patients with rationales for the treatments
information and knowledge rationales for treatment the patient about COPD asthma was conducted, and and efficiently explains
of resources as evidenced options including the exacerbations as this will the study concluded using health regimens to prevent
by the patient’s and importance on the use of engage the patient and empathy-building strategies COPD exacerbations.
caregivers’ statement of supplemental oxygen at caregivers in learning. within a framework of
concerns. (Ackley, Ladwig, home, cessation of patient-centered counseling
& Makic, 2017, p. 555- smoking, and use of an Reinforce learning through maximizes the The patient verbalizes
556). assistive device such as a constant repetition and effectiveness of self-care different health regimens
walker to avoid chronic follow-up sessions. interventions for that he has incorporated
obstructive pulmonary individuals with poorly into his lifestyle to better
disease (COPD) controlled asthma. Another his health and prevent
exacerbations. study concluded using COPD exacerbations.
multiple, or a combination
Within one week, the of teaching methods
patient will incorporate adapted to client learning
techniques that minimize systems and priority
and prevent COPD concerns was effective for
exacerbations into his patient outcomes. (Ackley,
lifestyle regimen. Ladwig, & Makic, 2017, p.
557).

A systematic review was


conducted and found that
frequent and regular
educational sessions,
including “boost” sessions,
Inessa Borovskiy 16
Nursing Diagnosis Short- & Long-Term Interventions Rationale Evaluation
(List 3-5 priority nursing Goals (Must complete in (Evidenced based rationale for (How did/will you evaluate the
diagnoses in order of priority.) (Must complete for EACH comprehensive manner for two each intervention for two highest effectiveness of planned
priority nursing diagnosis listed. highest priority nursing priority nursing diagnoses. interventions listed in previous
Goals should be SMART: diagnoses. Include collaborative Describe in your own words with column? HINT: Assess
specific, measurable, attainable, /interdisciplinary.) references cited here & in attainment of SMART goals.)
realistic, & time-framed.) reference list in APA format.)

improved medication and


self-care management
outcomes for individuals
with a chronic condition.

Activity intolerance related By the end of the shift, the Implement a traditional 6- Exercise training activities The patient has been
to an imbalance between patient will participate in minute walk distance to increase the patient’s participating in the
oxygen supply and demand the recommended physical evaluate the patient’s stamina leading to energy recommended physical
as evidenced by exertional activity using an assistive ability to walk. If necessary conservation while activities with the use of a
discomfort. (Ackley, device such as a walker as refer the patient to a minimizing dyspnea. walker and has walked for
Ladwig, & Makic, 2017, p. recommended by a physical physical therapist. Help COPD is a progressive 2 to 5 minutes around his
122). therapist to help decrease maintain recommended disease, and affected room five times.
shortness of breath on activity levels and teach the individuals can become
exertion and increase patient coordinated walking disabled because they must The patient has
stamina. with slow, pursed-lip use all available energy for demonstrated increased
breathing, breathing in breathing. Walking and tolerance for activities such
Within one week, the through the nose while other endurance exercises as walking for longer than
patient will demonstrate taking one stop, then such as cycling combined 20 minutes without
increased tolerance to breathing out through with strength training developing shortness of
activities. pursed lips while taking strengthen muscles and breath.
two to four steps. improve the patient’s
endurance. (Lewis,
Assist and walk with Dirksen, Heitkemper, &
patient monitoring and Bucher, 2014, p. 600)
providing verbal reminders
when necessary regarding Walking with the patient
the use of breathing helps decrease anxiety and
techniques to help conserve helps maintain a slow pace
energy. and enables to observe the
Inessa Borovskiy 17
Nursing Diagnosis Short- & Long-Term Interventions Rationale Evaluation
(List 3-5 priority nursing Goals (Must complete in (Evidenced based rationale for (How did/will you evaluate the
diagnoses in order of priority.) (Must complete for EACH comprehensive manner for two each intervention for two highest effectiveness of planned
priority nursing diagnosis listed. highest priority nursing priority nursing diagnoses. interventions listed in previous
Goals should be SMART: diagnoses. Include collaborative Describe in your own words with column? HINT: Assess
specific, measurable, attainable, /interdisciplinary.) references cited here & in attainment of SMART goals.)
realistic, & time-framed.) reference list in APA format.)

patient’s actions and


physiologic responses to
the activity. Patients with
COPD may become
anxious and fearful of
walking or performing
exercises. These patients
and their caregivers require
support while they build
the confidence they need to
walk or to perform daily
exercises. (Lewis, Dirksen,
Heitkemper, & Bucher,
2014, p. 600)

XIII. DOCUMENTATION (Write a note in AIE format – Assessment, Intervention/Implementation, Evaluation)

Focus: Activity intolerance

Assessment: At 1100 patient was sitting in a chair and was alert and oriented to person, time, place, and situation. Skin warm and dry with no

evidence of cyanosis. Blood pressure 120/55 measured on the patient's left arm while sitting in a chair, HR 99, RR 20, Temp. 36.7C, SpO2

90% on room air. Radial pulses 3+ bilaterally, capillary refill less than 2 seconds bilaterally on the upper and lower extremities. Patient

tolerates an active range of motion. Edema of +1 noted on the right lower extremity. Tremors noted on upper extremities bilaterally. Wheezes

heard bilaterally. Nonproductive dry cough. Normoactive bowel sounds in all four quadrants, abdomen nontender on palpation in all four
Inessa Borovskiy 18
quadrants. Hematoma noted on the right lower quadrant. The patient is exhibiting activity intolerance due to shortness of breath upon

exertion.

Implementation: MD notified of findings, and physical therapist (PT) asked to evaluate patient regarding tremors. PT arrived at 1414 to

assess the patient. PT recommended the patient use a walker and attempt to walk for at least two to five minutes as tolerated. Respiratory

sputum induction performed. Use of an incentive spirometer recommended ten times every hour.

Evaluation: Sputum induction performed with minimum sputum collected. Patient has been using an incentive spirometer ten times every

hour to increase secretion removal. The patient continues to attempt to walk at least two to five minutes as tolerated with a walker. The patient

will continue to work with PT. Will continue to monitor tremors on upper extremities bilaterally.

XIV. NARRATIVE SUMMARY OF DISCHARGE PLANNING, TRANSITIONAL CARE NEEDS, & INTERPROFESSIONAL

COLLABORATION

Discharge Planning & Transitional Care Needs (Include):

The patient is married and has two children, two daughters. The patient’s daughter is the patient’s primary caregiver. The patient lives with

his wife in an apartment complex. Educate the patient on the importance and of smoking cessation, use of an assistive device, walker, to

minimize shortness of breath and decrease the risk of falls, and the use of supplemental oxygen at home. The patient is compliment

understands the importance of taking his medications. However, the patient continues to be resistant to the use of supplemental oxygen at

home. The patient was educated on the importance of supplemental oxygen use at home. Outpatient services were recommended, and the

patient will continue to work with a physical therapist (PT).

Interprofessional Collaboration (Include):


Inessa Borovskiy 19
The patient was referred to a physical therapist, and consultation was conducted before discharge. An appointment with the patient's primary

health care provider has been scheduled for October 2nd at 9 AM at the patient's primary health care providers usual location.

References
Inessa Borovskiy 20
Ackley, J.B., Ladwig, B.G., & Makic, F.B.M. (2017). Nursing Diagnosis Handbook (11th Ed.). St. Louis, MO: Elsevier, Inc.

Ayello, E.A. (2017). Predicting Pressure Injury Risk. The Hartford Institute for Geriatric Nursing. (5). Retrieved from

https://consultgeri.org/try-this/general-assessment/issue-5.pdf

Hendrich, A. (2016). Fall Risk Assessment for Older Adults: The Hendrich II Fall Risk Model. The Hartford Institute for Geriatric Nursing. (8).

Retrieved from https://consultgeri.org/try-this/general-assessment/issue-8

Hodgson, B.B., & Kizior, R.J. (2016). Nursing Drug Handbook 2016. St. Louis, MO: Saunders Elsevier.

Kee, J.L., Hayes, E.R., McCuistion, L.E. (2015). Pharmacology: A Patient-Centered Nursing Process Approach. (8th Edition). St. Louis, MO:

Elsevier Saunders

Lewis, L.S., Dirksen, R.S., Heitkemper, M.M., Bucher, L. (2014). Medical Surgical Nursing Assessment and Management of Clinical Problems.

(9th ed.). St. Louis, MO: Mosby Elsevier.

Micromedex. (2018, August 21). Prednisone. Retrieved from https://www-micromedexsolutions-

com.proxy.library.nyu.edu/micromedex2/librarian/CS/9871AA/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDS

YNC/DB215E/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencex

pert.DoIntegratedSearch?SearchTerm=prednisone&UserSearchTerm=prednisone&SearchFilter=filterNone&navitem=searchALL#

Micromedex. (2018, September 17). Pregabalin. Retrieved from https://www-micromedexsolutions-

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NC/563B59/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpe
Inessa Borovskiy 21
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l#

Perry, G. A., Potter, A. P., & Ostendorf, R. W. (2014). Clinical Nursing Skills & Techniques (8th Ed.) St. Louis, MO: Mosby Elsevier.

Wallace, M., & Shelkey, M. (2007). Katz Index of Independece in Activities of Daily Living (ADL). The Hartford Institute for Geriatric

Nursing. (2). Retrieved from https://www.alz.org/careplanning/downloads/katz-adl.pdf