WEEKLY NURSING CARE PLAN Diagnosis- Status Asthmaticus History of present illness- Patient was admitted to the ICU

on 1/21/12 due to shortness of breath and wheezing. His nebulizer did not help thus his admission to the ICU. He was intubated while in the ICU and extubated on 1/26/12 and transferred to unit 3E. He has recovered quickly and ambulates without assistance. He will be discharged tomorrow which is 1/31/12. Past medical history- asthma Allergies- Levaquin Social history- Patient does not work due to his daily use of nebulizer. History of smoking 1 ppd for 15 years. Family history- Patient is divorced with two children. He presently lives with his girlfriend who is pregnant with twins. Surgical history- TEE and EGD on 1/25/2012 Subjective Data- I feel great now. I am glad I can breathe better as compared to about a week ago. I have trouble sleeping and always constipated because of the many steroid medications I am currently taking. I can t wait to be discharged tomorrow. Objective Data- Patient was lying in bed. Alert, awake and oriented x 3. His speech is sometimes not congruent to the line of conversation. PERRLA. Patient s face is symmetrical with no lesions present. Bilateral hand grasp equal. Capillary refill is less than 3 secs. Lung sounds are clear bilaterally. Heart sounds are regular with no extra sounds heard. Abdomen is soft, non-tender and bowel sounds are present in all four quadrants. There are no signs of edema present. Vital signs are as follows: BP- 146/64, pulse- 68, SpO2- 95% on room air, temp.- 98.1, resp.-20, pain- 0/10. 15.1 14.0 42.0 141 3.5 107 24 24 1.0

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Nursing Diagnosis

Expected Outcomes

Interventions

Evaluation

Risk for infection related to inadequate primary defenses as evidenced by patient s poor personal hygiene practices.

The patient will be able to keep the site of the PICC line clean from being infected after being discharged.

Educated the patient on the importance of keeping the site clean so the PICC line can last longer. Handouts were also given to the patient. Educated patient that smoking and asthma are detrimental to his health.

The patient was able to verbalize the instructions on keeping the PICC line site clean.

Ineffective airway breathing related to asthma as evidenced by patient stating that he smokes 1 pack of cigarette a day.

Patient will be able to gradually quit smoking.

Patient was able to verbalize the importance of quitting smoking. Patient stated he would search for smoking cessation programs in his area to attend. Patient was able to verbalize eating foods high in fiber to reduce his chances of having constipation.

Constipation related to Patient will Identify measures insufficient physical activity as that prevent or treat evidence by patients complaints constipation. of no bowel movement in the past three days.

Educated patient on the importance of drinking lots of fluids and eating foods high in fiber in order to make bowel movement easier.