PNS202 Dropbox Assignment Week 10 – Nursing  Care Plan Example

Learner’s Name:  J. Otto, RN   Date Due:  12/10/23

Patient’s Initials:  L. K.    Room #:  3319   Age: 52 Medical Diagnosis:  Asthma

                                                  NANDA Nursing Diagnosis

Assessment Data:

O –

O – T 99.1 F orally, P – 98, RR – 20, BP 142/82 mmHg, SpO2 94% on R/A

O – Integument:

S – Pain R

Nursing Diagnosis:

 

(NOTE to student:  NO AEB S & O data in ND statement b/c is a “Risk for” problem)

(NOTE to student:  You are to do only Actual problems in your NCP, not “Risk for” problems)

                                                            Patient Goal

(“Patient will”, “as evidenced by”)

Short-Term Goal/Desired Outcomes:

end of the teaching session this shift.

Long-Term Goal/Desired Outcomes:

 

 

                                              Nursing Interventions and Rationales

1.  Assess

Rationale:

2.

Rationale:

3.

Rationale:

 

                                Evaluation of Short-Term Goal/Desired Outcomes

Short-Term Goal:

 

 

                         

 

Reference

Ackley, B. & Ladwig, G. (2020).   Nursing diagnosis handbook.  An evidence-based guide to          planning care    (12 Ed.). St. Louis:  Elsevier.

 

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What critical findings (assessment and labs) indicate respiratory insufficiency and poor cerebral perfusion in severe TBI patients?

 

 

What is the immediate intervention for a spinal cord injury (SCI) patient that has decreased LOC?

 

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The nurse is caring for a client who has the following history and assessment findings: – T5 spinal cord injury SCI 6 months ago – Flushed face – Profuse sweating – Reports blurred vision – BP 184/95 – Pulse 68 -Pulse oximeter 95% What actions should the nurse take first?

• Assess the skin for pressure injury

• Adjust the room temp for comfort

• Prepare to administer enema Or Palpate clients bladder

 

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The nurse working in the emergency department is caring for a client who has myasthenia gravis. The client presents with bladder incontinence, dysphagia, absence of cough, respirations of 40 with dyspnea, and generalized weakness. Which of the following actions should the nurse take immediately?

• Administer atropine sulfate

• Gather intubation equipment

• Insert indwelling urethral catheter

• Set up bedside suction

 

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