Allergies:__PCN, Diprivan, Codine DNR:_Yes_________

Faulkner State Community College/Division of Nursing Clinical Care Plan Nursing 202 Student _____Kenneth Smith II______ Patients Initials __OD______ Clinical Week __11_____ Class: Nursing 202
Assessment Subjective: C/O DOA, SOB, weakness, nausea Objective: 1. P 102, RR 16/Labored at a irregular rhythm, O2 sat 92 FiO2 35 @ 12L/min T piece for trach 2. CXR = Lung hyperventilated and Reticular density at bases indicating possible atelectasis or mild chronic fibrosis 3. Lung Snds included some bilateral fine crackles throughout lung fields and bilateral lung snds 4. non productive coughing, general weakness, obesity, mobility (chair bound) Nursing Diagnosis Nursing Intervention

Room #:_76__

Rationale

Ineffective air way clearance R/T pulmonary muscle weakness, tracheal/bronchial inflammation, edema formation, increased production of thick tenacious sputum, tracheostomy; AEB P 102, RR 16/Labored at a irregular rhythm, Lung Snds included some bilateral fine crackles throughout lung fields and bilateral lung snds, O2 sat 92 FiO2 35 @ 12L/min T piece for trach, ABG (FiO2 40) = pH 7.37, pCO2 62.2, pO2 71, Bicarb 35.8, BE 8, O2 Sat 93 CXR = Lung hyperventilated and Reticular density at bases indicating possible atelectasis or mild chronic fibrosis, non productive coughing, general weakness, obesity, mobility (chair bound), C/O weakness, C/O constant fatigue, C/O Dyspnea of exertion S/T ESCOPD and Recent burns to upper airways, Smoker

1. Student Nurse will teach importance of deep breathing, coughing, and how they are performed 2. Student Nurse will assess VS and Neuro status Q4hr 3. Student Nurse will encourage pt to rest before and after strenuous actives. 4. Student Nurse will give PRN O2 for O2 Sats < 92%. 5. Student Nurse will maintain HOB 30 at all times. 6. Student Nurse will encourage Pt to perform ADLs with minimal assistance. 7. Student Nurse will give PRN pain and nausea meds per MDO and will encourage Pt to report pain, nausea, or discomfort promptly. 8. Student Nurse will have Pt ambulate as well tolerated.

1. Breathing exercises are import to tissue perfusion, healing and maintain current Rt status. 2. Routine assessments will bring to light potential problems and allows time to address them before they escalate. 3. Scheduled rest will decrease metabolic demands on the heart. 4. Adequate oxygen supply is necessary for tissue perfusion. 5. This helps to ease the effort of breathing. 6. This will help to maintain Pts ability to perform ADLs 7. Pain and nausea may inhibit Rt efforts. 8. Ambulation will increase cause the Pt to breath deep, expectorate and exercise pulmonary accessory muscles.

Allergies:__PCN, Diprivan, Codine DNR:_Yes_________

Room #:_76__

Desired Outcome 1. Pt will successfully perform breathing exercises between 0630-1430 on 4-9-12 2. Pt will discuss importance of breathing exercises between 0630-1430 on 4-9-12 3. Pt will have O2 sat > 92% between 0630-1430 on 4-9-12 4. Pt will perform ADLs at his maximum ability between 06301430 on 4-9-12 5. Pt will consistently rest before and after exertion between 0630-1430 on 4-9-12 6. Pt will have no increased c/o of usual dizziness or weakness between 0630-1430 on 4-9-12

Evaluation Goal 1[Achieved] Pt performed breathing exercises between 06301430 on 4-9-12 Goal 2[Achieved] Pt discussed and agreed w/ importance of breathing exercises between 0630-1430 on 4-9-12 Goal 3[Achieved] Pt had O2 sat > 92% between 0630-1430 on 4-9-12 Goal 4[Achieved] Pt performed ADLs at his maximum ability between 0630-1430 on 3-19-12 Goal 5[Achieved] Pt consistently rested before and after exertion between 0630-1430 on 4-9-12 Goal 6[Achieved] Pt will had no increased c/o of unusual dizziness or weakness between 0630-1430 on 4-9-12