Nursing Care Plan
Ashley Anderson
Client initials: M.D. Age: 63 Diagnoses: Hospital Acquired Pneumonia/ Fall at home
Assessment Plan
Diagnosis Goals/Outcomes
Ineffective Airway Goal- Demonstrates
Clearance R/T bronchial restoration of airway
inflammation AEB clearance to baseline.
Ineffective cough
Outcomes-
Patient will demonstrate
ways of how to achieve
airway clearance by
discharge.
Patient will display a
patent airway with breath
sounds clearing by
discharge.
Patient will maintain
absence of dyspnea and
cyanosis by discharge.
Acute Pain R/T persistent Goal- Pain level will return
coughing AEB patient to baseline.
statement
Outcomes- Patient will
demonstrate
resting/sleeping in relaxed
manner prior to discharge.
Patient will verbalize
control of pain at level less
than 3 on a pain scale of 0-
10.
Patient will verbalize
understanding of
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Interventions Rationale Evaluation
Nursing Orders
- Assess rate, - Tachypnea, shallow - Patient was absent
rhythm, and depth respirations, and of tachypnea and
of respiration, chest asymmetric chest shallow
movement, and use movement are respirations.
of accessory frequently present - Patient showed
muscles. because of improvement with
- Assess cough discomfort. coughing
effectiveness and - Coughing is most effectively.
productivity. effective way to - Patient had slight
- Auscultate lung remove secretions. decreased air flow
fields, noting areas - Decreased airflow and adventitious
of decreased or occurs in areas with breath sounds not
absent air flow and consolidated fluid. present.
adventitious breath
sounds.
- Assess pain - Can show if there - Patient reported a
characteristics. are any onset 2/10 on the pain
complications from scale for when he
pneumonia such as would cough.
pericarditis and - Patient’s vitals were
endocarditis. normal according to
- Monitor vital signs. - Changes in vitals patient’s baseline.
can mean patient - Patient was agitated
- Provide comfort may be and did not want to
measures and experiencing pain. go over relaxation
encourage - Patient involvement techniques at that
relaxation in pain relief time.
techniques. measures promotes
independence.

Decreased Activity
Tolerance R/T general
weakness AEB patient
displaying weakness with
activity
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nonpharmacological
interventions for pain relief
prior to discharge.
- Patient went to
Goal- Patient will - Encourage patient - Can help reduce restroom to do
demonstrate a measurable to practice deep- stress. personal hygiene
increase in tolerance in breathing exercises. and reported
activity. absence of dyspnea.
- Pace activity for - Effective coughing
Outcomes- Patient will patients with may exhaust an
report an increase in reduced activity. already - Upon arriving back
tolerance to activity with compromised from doing
absence of dyspnea prior to - Encourage patient patient. personal hygiene
discharge. to set realistic goals patient’s vitals were
for activity and - Setting realistic within acceptable
Patient will demonstrate progress. goals helps the range.
knowledge of what patient stay - Patient was not
breathing exercises to do motivated. interested in
prior to discharge. learning about
breathing exercises.
Patient displays vital signs
during activity that are
within patient’s acceptable
range prior to discharge.
 Nursing Care Plan

Assessment Plan Interventions Rationale Evaluation

Diagnosis Goals/Outcomes Nursing Orders

This study source was downloaded by 100000843162460 from CourseHero.com on 06-03-2023 12:40:21 GMT -05:00
 This study source was downloaded by 100000843162460 from CourseHero.com on 06-03-2023 12:40:21 GMT -05:00
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