Nursing Process Peter O. Case Study
The purpose of this paper is to establish an effective care plan for Peter O. The nursing process is used to analyze his assessment data and physical examination to establish a priority, a long-term, and a teaching nursing diagnosis. The paper will focus on evaluating subjective and objective data and determine attainable goals for the nursing diagnosis’ using proper nursing interventions and rationales.
Care Plan
Nursing Diagnosis (Priority): Impaired Gas Exchange related to alveolar-capillary membrane changes as evidenced by O2 saturation of 90% on room air, complaints of shortness of breath, and observed use of accessory muscles for respiration.
Data Cluster: Subjective:
Complaints of SOB …show more content…
Interventions: (source each)
1. Begin ambulation as tolerated (Nettina, 2014, p.287)
2. Encourage deep breathing and coughing exercises. Use incentive spirometer, chest physiotherapy, intermittent positive-pressure breathing, as indicated (Doegnes et al., 2016, p.360)
3. Humidify air or oxygen therapy (Nettina, 2014, p.288) Rationales: (source each)
1. This improves ventilation and secretion clearance and reduces risk of atelectasis and worsening pneumonia (Nettina, 2014, p.288)
2. This promotes optimal chest expansion, mobilization of secretions and oxygen diffusion (Doegnes et al., 2016, p.360)
3. This may loosen and mobilize secretions (Nettina, 2014, p.288)
Evaluation: Goal was met. Patient maintained an oxygen saturation greater than 96% by the end of 24 hours. Patient’s oxygen saturation levels will have continued to be monitored, and supplemental oxygen will be adjusted as needed.
Nursing Diagnosis (Long-term): Activity Intolerance related to imbalance between oxygen supply and demand as evident by verbal report of dyspnea on excretion.
Data Cluster: …show more content…
Be alert to signs of avoidance. (Doegnes et al., 2016, p.506) Rationales: (source each)
1. This provides a starting point, and determines if the client is physically, emotionally or mentally capable at this time. (Doegnes et al., 2016, p.506)
2. This will allow the client to feel competent and respected. (Doegnes et al., 2016, p.507)
3. The client may need to suffer the consequences of lack of knowledge before his is ready to accept information (Doegnes et al., 2016, p.506)
Evaluation: Goal was met. Client exhibited interest and assumed responsibility for learning by looking for information and asking questions by the end of the day. The client will be provided with further teachings now that personal responsibility and interested was exhibited.
Goal #2: (Long Term)
Patient will verbalize understanding of necessary lifestyle changes and participate/maintain changes by time of discharge. Interventions: (source each)
1. Provide written information or guidelines and self-learning modules for client to refer to as necessary (Doegnes et al., 2016, p.508)
2. Provide positive reinforcement and avoid the use of negative reinforcers. (Doegnes et al., 2016,
The purpose of this paper is to establish an effective care plan for Peter O. The nursing process is used to analyze his assessment data and physical examination to establish a priority, a long-term, and a teaching nursing diagnosis. The paper will focus on evaluating subjective and objective data and determine attainable goals for the nursing diagnosis’ using proper nursing interventions and rationales.
Care Plan
Nursing Diagnosis (Priority): Impaired Gas Exchange related to alveolar-capillary membrane changes as evidenced by O2 saturation of 90% on room air, complaints of shortness of breath, and observed use of accessory muscles for respiration.
Data Cluster: Subjective:
Complaints of SOB …show more content…
Interventions: (source each)
1. Begin ambulation as tolerated (Nettina, 2014, p.287)
2. Encourage deep breathing and coughing exercises. Use incentive spirometer, chest physiotherapy, intermittent positive-pressure breathing, as indicated (Doegnes et al., 2016, p.360)
3. Humidify air or oxygen therapy (Nettina, 2014, p.288) Rationales: (source each)
1. This improves ventilation and secretion clearance and reduces risk of atelectasis and worsening pneumonia (Nettina, 2014, p.288)
2. This promotes optimal chest expansion, mobilization of secretions and oxygen diffusion (Doegnes et al., 2016, p.360)
3. This may loosen and mobilize secretions (Nettina, 2014, p.288)
Evaluation: Goal was met. Patient maintained an oxygen saturation greater than 96% by the end of 24 hours. Patient’s oxygen saturation levels will have continued to be monitored, and supplemental oxygen will be adjusted as needed.
Nursing Diagnosis (Long-term): Activity Intolerance related to imbalance between oxygen supply and demand as evident by verbal report of dyspnea on excretion.
Data Cluster: …show more content…
Be alert to signs of avoidance. (Doegnes et al., 2016, p.506) Rationales: (source each)
1. This provides a starting point, and determines if the client is physically, emotionally or mentally capable at this time. (Doegnes et al., 2016, p.506)
2. This will allow the client to feel competent and respected. (Doegnes et al., 2016, p.507)
3. The client may need to suffer the consequences of lack of knowledge before his is ready to accept information (Doegnes et al., 2016, p.506)
Evaluation: Goal was met. Client exhibited interest and assumed responsibility for learning by looking for information and asking questions by the end of the day. The client will be provided with further teachings now that personal responsibility and interested was exhibited.
Goal #2: (Long Term)
Patient will verbalize understanding of necessary lifestyle changes and participate/maintain changes by time of discharge. Interventions: (source each)
1. Provide written information or guidelines and self-learning modules for client to refer to as necessary (Doegnes et al., 2016, p.508)
2. Provide positive reinforcement and avoid the use of negative reinforcers. (Doegnes et al., 2016,