Nursing
Diagnosis (ND)
X (2)
Note:
There needs to be 2 different NDs for your patient.
E.g.,
Ineffective breathing pattern related to the patients decreased function in lung expansion as evidenced by dyspnoea…
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Clues
Note:
What are the subjective and objective clues that you have gathered to makes you think of ND
E.g.,
decreased o2 Sats,
Coughing
Difficulty beathing with full work of muscles
Pt. reported pain when breathing
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Intervention
X (2)
Note:
You need to supply at least 2 interventions for each ND
E.g.,
Correctly sit patient up in a more up right position
(Smith & Bruce, 2020).
Check with the nurse in charge for the use of oxygen for Pt.
(Arnott H, 2018)
Monitoring o2 Sats levels more regularly
(Peters & Brown, 2021)
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Rationale
X (2) or more
Note:
For each intervention you come up with for your patient, you will need to supply a different rationale for each intervention.
E.g.,
The patient has better air entry when sitting upright
Oxygen will help bring the o2 levels back to a higher level
Keep actively monitoring o2 Sats level to gauge Pt. airway improvement and document.
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Goals / Expected
Outcomes for Patient
Note:
You need to give S.M.A.R.T goals and timelines for the interventions to work.
E.g.,
S – specific
M – measurable
A – achievable
R – realistic
T – Timely
Have the Pt.’s breathing under control in a timely manner (within 15 mins) so the Pt. can settle. After applying O2, (6lts as directed by nurse in charge) Sats levels will return to a normal level Continue observations and reassurance.
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Evaluation
Note:
You need to say if the intervention worked, as the evaluation part alerts the nurse to change the care plan if that intervention has not worked.
E.g.,
Yes, O² Sats returned to 98% within time frame as Pt.’s saturation levels were taken every 10mins until normal level reached.
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