Professional Documents
Culture Documents
Care Plan Peds
Care Plan Peds
Admitting Diagnosis Asthma Rationales Evaluation: Were the goals met? Evaluate each Short Term goal: Goal Met, oxygenation saturation 95%
Nanda Dx and Statement: Nursing Dx Impaired gas exchange r/t altered oxygen supply, retained secretions AEB: Subjective Mother says, he is not coughing out the mucus and the rescue inhaler was not helping him anymore Objective Dyspnea Labored respirations Elevated shoulders.
Goals: Short Term/Long Term One Short term: Child will have adequate airway exchange within second of admission to ER.
Nursing Interventions
Attempting to maintain oxygen saturation at greater than 90% (Gulanick Nursing Care Plans 7th edition, evolve web page) Cool, pale skin may be secondary to a compensatory vasoconstrictive response to hypoxemia. As oxygenation and perfusion become impaired, peripheral tissues become cyanotic. (Gulanick Nursing Care Plans 7th edition evolve web page) Useful tool to detect changes in oxygenation. Oxygen saturation should be maintain at 90% or greater. (Gulanick Nursing Care Plans 7th edition evolve web page)
2. Assess skin, nail beds and mucous membranes for pallor or cyanosis. (I)
One Long Term 3 Educational Goal 1. Educate child and Goals family regarding proper Child will demonstrate use of rescue improve blood gases, medications in case of within the patients disease exacerbation.(i) normal range, within 2 days.
To prevent illness exacerbations and hospitalization; to prevent side effects from improper use of certain asthma drug. (Hockenberry, Wongs essential of Pediatric Nursing 8th edition pg. 793) To control symptoms and minimize shortness of breath. (Hockenberry, Wongs essential of Pediatric Nursing 8th edition pg. 793) Reinforces need for realistic plan of follow up and anticipatory guidance. (Newfield, Cox Clinical applications of Nursing Diagnosis 5th edition pg 348)
Evaluate each Long Term goal: Goal met and on going assessment of blood gases.
2. Educate child and family in the use of inhaled corticosteroids and bronchodilator.(I)
3. Educate child and family regarding follow up care and protection from triggering events, including exposure to respiratory infections. (I) 3 Diagnostic 1. Assess respirations noting quality, rate, rhythm, depth and breathing effort (I)
Both rapid, shallow breathing patterns and hypoventilation affect gas exchange. (Gulanick Nursing Care Plans 7th edition evolve web page)
Changes in lung sounds may reveal the etiology of impaired gas exchange. (Gulanick Nursing Care Plans 7th edition evolve web page) Pco2, Po2 and O2 saturation are indicators of the efficiency of gas exchange. (Newfield, Cox Clinical applications of Nursing Diagnosis 5th edition pg 348
Student:
Admitting Diagnosis
Rationales There should be 1 rationale per intervention and a reference. Include Author, Name of Book, Year, and pg. # for each rationale
One Short term (This includes the NANDA dx with Goals must be: the r/t and the 4 Measurable AEB (this should 5 Observable be broken down 6 Timed into subjective and 7 Realistic objective data) 8 Specific
Evaluation: Were the goals met? Evaluate each Short Term goal: This looks at the goals.
One Long Term Goal Goals must be: 1. Measurable 2. Observable 3. Timed 4. Realistic 5. Specific
There should be 1 rationale per intervention and a reference. Include Author, Name of Book, Year, and pg. # for each rationale
Student:
There should be 1 rationale per intervention and a reference. Include Author, Name of Book, Year, and pg. # for each rationale Admitting Diagnosis
Rationales There should be 1 rationale per intervention and a reference. Include Author, Name of Book, Year, and pg. # for each rationale
One Short term (This includes the NANDA dx with Goals must be: the r/t and the 9 Measurable AEB (this should 10 Observable be broken down 11 Timed into subjective and 12 Realistic objective data) 13 Specific
Evaluation: Were the goals met? Evaluate each Short Term goal: This looks at the goals.
One Long Term Goal Goals must be: 6. Measurable 7. Observable 8. Timed 9. Realistic 10. Specific
Student:
There should be 1 rationale per intervention and a reference. Include Author, Name of Book, Year, and pg. # for each rationale 3 Diagnostic There should be 1 (label each interventions as rationale per independent, dependent, or intervention and interdependent/collaborative) a reference. Include Author, Name of Book, Year, and pg. # for each rationale Patient Initials: Admitting Diagnosis Age: m/ f Nursing Interventions (label each interventions as independent, dependent, or interdependent/collaborative) 3 Therapeutic Rationales
3 Educational
3 Diagnostic