Nursing Case Study: Nursing Care Plan For Pc Kohler

NURSING CARE PLAN

Patient’s Initials: CH Student’s Name: PFC Kohler

Medical Diagnosis: Spine-HALO Application Date:10/12/2016

1. PROBLEM 2. GOAL/ OUTCOME 3. INTERVENTIONS 4. RATIONALE 5. EVALUATION

Dx: Activity intolerance

R/T: inefficient work of breathing

AEB: Shortness of breath during and after ADL’s

SUB

Mother reports “She cannot walk very far before needing her wheel chair”.

OBJ

SOB during ambulation

Sa02 – 94%

Respiratory Rate - 35

ST 1:.

Patient will display adequate gas exchange as evidence by SaO2 values and respiratory rate consistent with baseline.

LT 1:

Patient will be able to maintain ADL’s without displaying excessive wob by time of discharge 1)Nurse will monitor

LT 1: Goal Not Met

Patient not yet discharged form hospital.

6. DISCHARGE PLANNING/PATIENT TEACHING NEEDS

1)Recognize signs and symptoms of respiratory distress that must be reported to physician

2)Effectively demonstrate understanding of nan pharmacological techniques used to manage shortness of breath

3)Patient will demonstrate understanding of the importance of participating in activities

4)Patient and family will verbalize understanding of the importance of following the therapeutic plan for improving activity tolerance.

STUDENT NURSING CARE PLAN

Patient’s Initials:KH Student’s Name: PFC Kohler

Medical Diagnosis: Spine-HALO Application Date: 10/13/2016

1. PROBLEM 2. GOAL/ OUTCOME 3. INTERVENTIONS 4. RATIONALE 5. EVALUATION

Dx: Risk for impaired skin integrity

R/T: Mechanical interruption of skin and tissue

AEB:

SUB

Pain score 3/10

OBJ

ST 1:.

Patient will report any pain or discomfort during course of 12hr