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Running head: CARE PLAN 1

Care Plan Assignment

Student’s Name

Institutional Affiliation

CARE PLAN 2

Care Plan Template

Nursing Diagnosis: Ineffective breathing transpired in various circumstances such as hypoxia, heart failure, ankle edema,

abnormal ABGs, fluid overload, fatigue, and oxygen saturation of 88%

____________________________________________________________________________________

Assessment Data

Goal/Outcomes

Nursing Interventions

Rationale/Evidence Based

Evaluation

The nurse used

fatigue, ankle edema,

dyspnea and dizziness

as the subjective

information that led to

the diagnosis of the

ineffective breathing.

The ankle edema, fluid

Ensuring that

patient gains

normal breathing

characterized by

normal heart beats

and lack of

congestion in the

chest was the

primary objective

1. Patient needed to be put under

supplementary oxygen as

recommended by the doctor.

1. The patient with pulmonary

congestions typically suffers from

the development of hypoxia which

leads to congestive heart failure

hence the need for supplementary

oxygen because the patient will not

be able to naturally acquire the

normal oxygen concentration

(Lewis et al., 2013). Based on the

Ineffective

breathing is the

biggest challenge

to the patient and

getting the

respiratory to

normal by ending

the dyspnea

means the

CARE PLAN 3

retention, irregular

ABGs of PCO2 61,

PO2 49, PH 7.26,

respiratory rate of 26

and O2 Sat 88% was

the objective

information that

assisted in the

diagnosis.

is this nursing

assessment.

2. The patient needs to put under the

prescribed medications but the

effectiveness and side effects of such

medicine need to be evaluated

periodically to access any need to

change the medicines.

fact that the patient has low oxygen

concentration-88%, it was obvious

that the patient had hypoxia. The

patient is given supplementary

oxygen to improve the symptoms

hypoxia.

2. To improve the condition of the

patient, excess fluids in the chest

cavity need to be removed using

diuretics to improve the condition

of the symptoms of hypoxia and

ankle edema. Even with diuretics as

a medical option, they are linked to

side effects like electrolyte

imbalance and hypotension due to

volume depletion (Lewis et al.,

treatment will

have been

successful. There

was a progressive

effect to improve

of the breathing

rate symptoms,

from 26 to 21.

The absence

breathing

difficulty has

been reported by

the patient.

However, the

patient still have

symptoms of

CARE PLAN 4

3. Observe the patient’s respiratory

rate, oxygen saturation, heart rate and

blood pressure, and evaluate cases of

Orthostatic hypotension.

2013).Although the symptoms of

the patient will improve after

diuretics prescription it is important

that the nurse monitors these

improvements so that the

medication can be adjusted.

3. The oxygen saturation of the

patient is 88% and the respiratory

rate is elevated to 26. There is a

need of periodic review of oxygen

saturation, blood pressure,

respiratory rate, and heart rate to

assist in assessing the medication’s

effectiveness in improving the

respiratory rate.

The evaluation is also essential in

hypoxia.

The nurse need to

review the entire

process by

including patient

education on the

means to deal

with the

ineffectiveness in

breathing such as

Diaphragmatic

and pursed-lip to

maintain the chest

clear.

CARE PLAN 5

4. Measure and record the patient’s

weight daily and inform the doctor in

case of any changes between 1.00

and 1.50 kg.

asserting the need to adjust the

medications. Assessment of

Orthostatic hypotension and blood

pressure is vital evaluating the

patient’s fluid loss as the CHF has

diuretics (Lewis et al., 2013).

4. The symptoms of hypoxia in the

patient are caused by fluid

overload. Measuring the patient’s

daily weight helps in the

assessment of his fluid retention

and the medication’s effectiveness.

It also helps to monitor cases of

excess fluid loss which indicates

dehydration. Weight changes

observed has an indication on the

CARE PLAN 6

symptoms and are communicated to

the doctor in order to make medical

adjustments (Lewis et al., 2013).

CARE PLAN 7

References

Lewis, S.L., McLean Heitkkemper, M., Ruff Dirksen, S., Barry, M.A., Goldsworthy, S., & Goodridge, D. (2013). Medical-surgical

nursing in Canada. (3

Cdn. ed.). Toronto, ON: Elsevier

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Paper type

Deadline

Page count

550 words

Total price: $ 15.00

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