Student:Diana Sevilla

Patient Initials:

Age: 7 M

Admitting Diagnosis

Asthma

Nanda Dx and Statement:

Goals:Short Term/Long Term

Nursing Interventions Rationales Evaluation:Were the goals met?

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”

ObjectiveDyspneaLabored respirationsElevated shoulders.

One Short term:Child will have adequate airway exchange within second of admission to ER.

3 Therapeutic1. Maintain oxygen

administration device as ordered. (C)

2. Assess skin, nail beds and mucous membranes for pallor or cyanosis. (I)

3. Use pulse oximetry to monitor oxygen saturation (I)

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)

Evaluate eachShort Term goal:Goal Met, oxygenation saturation 95%

One Long Term 3 Educational Evaluate each

GoalGoalsChild will demonstrate improve blood gases, within the patient’s normal range, within 2 days.

1. Educate child and family regarding proper use of rescue medications in case of disease exacerbation.(i)

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)

To prevent illness exacerbations and hospitalization; to prevent side effects from improper use of certain asthma drug. (Hockenberry, Wong’s essential of Pediatric Nursing 8th edition pg. 793)

To control symptoms and minimize shortness of breath. (Hockenberry, Wong’s 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)

Long Term goal:Goal met and on going assessment of blood gases.

3 Diagnostic1. 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)

2. Assess lung sounds (I)

3. Collaborate with health care team regarding monitoring ABGs (C)

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: Patient Initials: Admitting Diagnosis

Age: m/ f

Nanda Dx and Statement:

Goals:Short Term/Long Term

Nursing Interventions Rationales Evaluation:Were the goals met?

One Educational

(This includes the NANDA dx with the r/t and the AEB (this should be broken down into subjective and objective data)

One Short term

Goals must be:4 Measurable5 Observable6 Timed7 Realistic8 Specific

3 Therapeutic(label each interventions as independent, dependent, or interdependent/collaborative)

There should be 1 rationale per intervention and a reference. Include Author, Name of Book, Year, and pg. # for each rationale

Evaluate eachShort Term goal:This looks at the goals.

One Long Term GoalGoals must be:

1. Measurable2. Observable3. Timed4. Realistic5. Specific

3 Educational(label each interventions as independent, dependent, or interdependent/collaborative)

There should be 1 rationale per intervention and a reference. Include Author, Name of Book, Year, and pg. # for each rationale

Evaluate eachLong Term goal:This looks at the goals.

3 Diagnostic(label each interventions as independent, dependent, or interdependent/collaborative)

There should be 1 rationale per intervention and a reference.

Include Author, Name of Book, Year, and pg. # for each rationale

Student: Patient Initials:

Age: m/ f

Admitting Diagnosis

Nanda Dx and Statement:

Goals:Short Term/Long Term

Nursing Interventions Rationales Evaluation:Were the goals met?

One Psychosocial

(This includes the NANDA dx with the r/t and the AEB (this should be broken down into subjective and objective data)

One Short term

Goals must be:9 Measurable10 Observable11 Timed12 Realistic13 Specific

3 Therapeutic(label each interventions as independent, dependent, or interdependent/collaborative)

There should be 1 rationale per intervention and a reference. Include Author, Name of Book, Year, and pg. # for each rationale

Evaluate eachShort Term goal:This looks at the goals.

One Long Term GoalGoals must be:

6. Measurable7. Observable8. Timed9. Realistic10. Specific

3 Educational(label each interventions as independent, dependent, or interdependent/collaborative)

There should be 1 rationale per intervention and a reference. Include Author, Name of Book, Year, and pg. #

Evaluate eachLong Term goal:This looks at the goals.

for each rationale3 Diagnostic(label each interventions as independent, dependent, or interdependent/collaborative)

There should be 1 rationale per intervention and a reference. Include Author, Name of Book, Year, and pg. # for each rationale

Student: Patient Initials:

Age: m/ f

Admitting Diagnosis

Nanda Dx and Statement:

Goals:Short Term/Long Term

Nursing Interventions(label each interventions as independent, dependent, or interdependent/collaborative)

Rationales Evaluation:Were the goals met?

One Short term

3 Therapeutic Evaluate eachShort Term goal:This looks at the goals.

One Long Term Goal 3 Educational Evaluate eachLong Term goal:

This looks at the goals.

3 Diagnostic