Nursing Care Plan – Amanda Carpenter

Initials: M.J.
Significant Medical Diagnoses: Cerebrovascular accident (mini stroke) 2010 Jan 15, Hypertension,
Hyperthyroidism, Macular degeneration (blind) rt. eye, Chronic Leukemia, Basal cell Carcinoma of skin
Safety Considerations: Resident independence, OTC medication use, self-reported heart condition with fluid
Activities of Daily Living/Activity level and restrictions: Independent. PRN 1x assist
Assessment of issue (NANDA Nursing Diagnosis): Risk for Respiratory Distress
Assessment Outcomes Interventions or Plan Rationale for Interventions Evaluation or result
Issue of Short term:
Short term: 1.Head of bed 45 when 1.GAEB (Good Air
exploration: Decrease 1.Position resident in supine increases thoracic Entry Bilaterally)
Risk for resident’s semi-Fowler’s position capacity, full ROM of and reduction in
Respiratory respiratory with bed mechanics diaphragm, and increased dyspnea and RR
Distress rate below and pillows lung expansion by 2.Resident self-report
30 breaths2.Situating in personal decreased abdominal improved mood,
Subjective data:
per minute context to decrease crowding. nurse-client
Sore throat,
by the end anxiety by increasing 2.Anxiety can increase relationship, and
Sore tongue,
of shift nursing companionship dyspnea and respiratory reduction in
Pain radiates to
time and building rate. Companionship to dyspnea and RR
the left ear,
therapeutic relationship situate in personal context 3.Resident’s
Weakness,
3.Monitor respiratory promotes relaxation, respiratory rate
Poor sleep
status (Sp02, GAEB, healing, and further below 30 breaths
quality,
RR), by auscultation of reduction in respiratory per minute by last
LTC Staff
chest and use of pulse rate. assessment of shift
provides less
oximeter, each hour on 3.Pulse oximeter and
care due to
shift. Report all auscultation are effective
resident’s level
findings immediately methods to identify changes
of independence,
Taking OTC in oxygenation. Monitoring
lozenges oxygenation and reporting
provided by is a safety measure to
granddaughter minimize resident risk.
Long term: Long term: Long term: Long term:
Objective data: Resident to 4.Facilitate 4.Promotes effective patient 4.Completion of
Sp02 95% resolve interdisciplinary care, and physician required physician
RR 32 episodic collaboration with to rule out or treat dyspnea assessment and
(Dyspnea) risk of physician to assess secondary to infection admin. of treatment
HR 72 respiratory respiratory risk 5.Nursing assistance with as per order to
Tympanic distress by etiology and treatment ADLs helps conserve decrease dyspnea
Temp. 37.3C absence of options within 7 days resident energy and and pain
BP 92/59 dyspnea and 5.Increase food and fluid assisting meals encourages 5.Resident
SOBOE pain in one intake by assisting 3 greater intake for improved maintaining bedrest
Increased month meals per day nutrition to promote health with ADL
abdominal in 6.Resident and staff 6.Informing the circle of care assistance to
drawings teaching/education. to protect resident safety. decrease dyspnea
Absence of Resident education for Increasing assistance will and increase pain
edema in lower use of call bell for any prevent overexertion and resolution
extremities physical changes. Staff promoting call bell use will 6.Education/teaching
Non-productive education of resident help to inform care and creates a reduction
cough status and new readily address any changes in pain severity and
Restlessness limitations. in physical status dyspnea