Nur 201 Care Plan

NAME

West Virginia Junior College

NUR 201

Instructor: NAME

DATE
 CARE PLAN TEMPLATE:
Assessment Nursing Planning Implementation Rationale Evaluation
Diagnosis
Subjective: Identify the two Identify two independent (not All interventions should include a Explain the why How would the
-SOB most likely collaborative) nursing interventions. measurable outcome, a timeline of when behind what you have intervention be
-Weakness/Fatigue hypotheses of the They must be listed in the highest to the outcome should be achieved and chosen. evaluated?
-Pt states “I feel client’s health lowest priority. One of the two must how will you evaluate whether the
status address potential risks. outcome was achieved.
like I can’t S.B. has anxiety Constant monitoring of
breathe.” related to the use of S.B.’s SpO2,
Impaired gas Maintain appropriate levels of S.B. will verbalize understanding of
-Numbness in the the BiPAP machine. By respirations, and pulse
exchange r/t supplemental oxygen therapy for oxygen supplementation and other
fingers evaluating her while to ensure that S.B. is
altered delivery clients with impaired gas exchange therapeutic interventions before and
she is using the receiving the
of inspired and hypoxemia during oxygen therapy. I will continue
Objective: machine, I can help appropriate flow of
oxygen AEB to monitor S.B.’s understanding of
-Decreased breath address her anxieties oxygen through the
cyanosis, Monitor oxygen saturation continuous oxygen therapy
sounds and fears and biPAP.
changes in vital continuously using pulse oximetry throughout her treatment in the
-Coughing- No implement non-
signs, and (SpO2) Emergency room until she is admitted
sputum pharmacological Monitoring S.B.’s ABGs
hypoxia upstairs onto the floor.
-Cyanotic/Pale methods to help her to look for signs of
Discuss with MD the potential
-Pursed lip relax and improve her respiratory acidosis
need for parenteral feeding. After starting oxygen therapy, S.B. will
breathing airflow.
Risk for demonstrate improved ventilation
-Using accessory
Infection: Risk Auscultate breath sounds every 1 and adequate oxygenation as
muscles with
factor: to 2 hours. The presence of evidenced by blood gas levels within
inspiration Getting S.B.’s SpO2
inadequate crackles and wheezes may alert normal parameters. I will continue to
-Cachexia under control will
nutrition the nurse to airway obstruction, monitor her SpO2 levels to ensure
-O2- 48% ensure that she has
which may lead to or exacerbate that they are within defined limits.
-RR-23 adequate tissue
existing hypoxia.
-Pulse- 50 perfusion and does
Ackley, B. J., Ladwig, G. B., Makic, M.
-BP- 118/41 not start to
Ackley, B. J., Ladwig, G. B., Makic, F., Martinez-Kratz, M., Zanotti, M.
-Weight- 66lbs experience signs and
M. F., Martinez-Kratz, M., Zanotti, (20210826). Nursing Diagnosis
1.6oz symptoms of
M. (20210826). Nursing Diagnosis Handbook, Revised Reprint with
-Anxious respiratory acidosis.
Handbook, Revised Reprint with 2021-2023 NANDA-I® Updates, 12th
2021-2023 NANDA-I® Updates, Edition. [[VitalSource Bookshelf
12th Edition. [[VitalSource version]]. Retrieved from
Bookshelf version]]. Retrieved vbk://9780323875707
from vbk://9780323875707
MEDICATIONS:
1. Acetaminophen Tablet 325 mg ORAL (Fever/Pain)

2. Albuterol Sulfate Inhalation Aerosol Solution 108 mcg ORAL (COPD)

3. Breo Ellipta Inhalation Aerosol Powder Breath Activated 100-25 mcg ORAL(COPD)

4. hydroxyzine HCl Oral Tablet 25 mg- (Anxiety)

5. Mirtazapine Oral Tablet 15 mg- (Major Depressive disorder)

6. Sertraline HCl Oral Tablet 50 mg- (Major Depressive Disorder)

7. Spiriva Resplmat Inhalation Aerosol Solution 2.5 mcg- (COPD)

8. Zofran Tablet 4 mg- IV (Nausea and vomiting)

9. Doxycycline Hyclate 100 mg- IV (Infection (Pneumonia))

While using the Beer’s list, I found that there are some potentially harmful medications that S.B. has been taking.

Hydroxyzine is an antihistamine that is used to control anxiety and tension caused by nervous and emotional conditions. Appropriate studies
performed to date have not demonstrated geriatric-specific problems that would limit the usefulness of hydroxyzine in the elderly. However,
elderly patients are more likely to have unwanted side effects (e.g., confusion, drowsiness) and age-related liver, kidney, or heart problems,
which may require caution and an adjustment in the dose for patients receiving hydroxyzine. (Hydroxyzine (Oral Route) Side Effects - Mayo
Clinic, n.d.)

Mirtazapine should be used with caution in elderly patients. However, elderly patients are more likely to have confusion or unusual drowsiness
and age-related liver, kidney, or heart problems, which may require caution and an adjustment in the dose for patients receiving mirtazapine.
Although this medication should be used with caution in elderly patients, It may be the preferred antidepressant in anorexic elderly individuals
with insomnia. (“Ags Ags Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Guideline Summary,” n.d.)
 1. S. B
1. Patient Name
2. Respiratory
What is going 2. Diagnosis
S on with the 3. Current issues
failure/Cachexia/COPD
Situation exacerbation/Pneumonia
patient? 5. Severity of
3. Low SpO2/Cyanotic/Hypoxic
symptoms/issues
4. S.B. is experiencing a severe exacerbation
of COPD symptoms AEB O2 48%
1. COPD, Cachexia, Failure to thrive,
1. Pertinent medical Respiratory failure, Major depressive
history 2. disorder, Anxiety, Pneumonia
Physician/consultants 2. Currently in the Emergency Department
What is the
B Clinical
3. Pertinent 3. CTA of the chest, X-Ray,
Background tests/treatments Oxygen
Background?
4. Code status therapy/Antibiotics
5. Behavioral/Psychosocial 4. DNR
6. Safety needs 5. Major depressive disorder,
anxiety. Widowed/No kids
6. Fall risk/Failure to thrive
1. BP- 118/41, Temp- 97.7F, HR- 102, RR- 23,
1. Vital signs SpO2- 48%
2. Pertinent physical 2. Decreased breath sounds, SOB,
What are the
assessment findings hypoxia, pursed lip breathing, using
problem areas
3. Pain assessment accessory
A and where is
4. Labs and diagnostic muscles to breathe
the patient in
Assessment tests 5. 3. 0/10
terms of the
Medications given/ 4. CTA of the chest, Chest X-Ray
care plan?
response 5. Antibiotics/Albuterol through BiPAP- O2
6. Treatments/Response SAT- 100%
6. IV fluids/ BiPAP- O2 100%
 1. (Physician) What would
you like me to do? 1. Continue to administer supplemental
2. (Nurse/Health care oxygen therapy
What could be team) You might 2. Provide non-pharmaceutical therapy to
R done to consider/I recommend help S.B. cope with severe anxiety due to
enhance/correct that you… BiPAP- (Warm blankets, lights down low,
Recommendations
the situation? 3. Uncompleted music, etc.)
tasks/medications 3. N/A
4. Issues that may need to 4. Decline in S.B.’s status and monitoring I/O
be addressed

Analyzing cues

S.B. has failure to thrive AEB weighing 66.16 lbs. In elderly patients, failure to thrive is associated with increased infection rates. (Robertson &
Montagnini, 2014) She was recently diagnosed with right lower lobe pneumonia and presents with a cough without sputum production. Her
SpO2 has fallen to 48% resulting from the spaces in her lungs filling with mucus. I will continue to monitor her O2 levels to ensure that she is
receiving the appropriate amount of oxygen through BiPAP.

S.B. is at high risk of skin breakdown due to being frail and having decreased mobility due to dyspnea on exertion. Requires maximum assistance
to move and exert. Boney prominences are profound which increases the risk of skin breakdown. I will implement a regular turning schedule
and frequent monitoring of boney prominences to ensure that skin remains intact. I will also elevate heels on pillows to reduce pressure.

S.B. Is a fall risk due to her low SpO2 levels and cachexia. Sarcopenia refers to the age-related reduction in strength, muscle mass, and
functionality which increases the risk of falls, injuries, and fractures. Sarcopenia is associated with other age-related conditions such as
osteoporosis, frailty, and cachexia. I will have S.B. demonstrate the use of the call bell and have her implement it if she needs assistance. I will
also frequently check on her to ensure that she is safe.
S.B. Has diagnoses of major depressive disorder and anxiety. While in the emergency room, she is experiencing increased anxiety due to having
the BiPAP placed and having low SpO2 levels. I will monitor her anxiety and implement the use of non-pharmacological measures such as
warm blankets, lights turned down low, soft music, and using therapeutic communication to understand her fears and anxieties to help her
cope.

References

Hydroxyzine (Oral route) side effects—Mayo clinic. (n.d.). Retrieved February 4, 2023,

from https://www.mayoclinic.org/drugssupplements/hydroxyzine-oral-route/side-effects/drg-

20311434?p=1#:~:text=Hydroxyzine%20is%20used%20to%20help,and%20atopic%20and%20contact%20dermatoses).
Ags ags beers criteria for potentially inappropriate medication use in older adults guideline summary. (n.d.). Guideline Central.

Retrieved February 5, 2023, from https://www.guidelinecentral.com/guideline/340784

Ackley, B. J., Ladwig, G. B., Makic, M. F., Martinez-Kratz, M., Zanotti, M. (20210826). Nursing Diagnosis Handbook, Revised

Reprint with 2021-2023 NANDA-I® Updates, 12th Edition. [[VitalSource Bookshelf version]]. Retrieved from vbk://9780323875707

Robertson, R. G., & Montagnini, M. (2014). Geriatric failure to thrive. American Family Physician, 70(2), 343–350.

https://www.aafp.org/pubs/afp/issues/2004/0715/p343.html