A CARE PLAN

1
A CARE PLAN

• The Basics

2
Diagnosis

• Medical vs. Nursing
• Medical disease process name
• Nursingfunctions to address the patient as a
  whole
• EX Medical Diagnosis Myocardial Infarction
• Nursing Diagnosis Acute Pain, R/T myocardial
  ischemia

3

• Nursing Diagnosis
• Acute Pain, R/T myocardial ischemia
• Decreased Cardiac Output R/T negative ionotropic
  changes in the heart 2ndary to myocardial
  ischemia or injury
• Impaired Gas Exchange, R/T decreased cardiac
  output
• Anxiety/Fear R/T hospital admission and fear of
  death

4
5 components

• Problem dyspnea, pain, confusion etc
• Diagnosis- (Nsg) Ineffective Airway Clearance
• Interventions-treatments provided to pt.
• Expected Outcomes-how will the patient react to
  treatments.
• Rationale-why are these interventions done?

5
Problems

• Shortness of breath
• Inability to do ADLs
• Pain control

6
Expected Outcomes

• The patient will
• have decreased pain as exhibited by pain scale
• Perform ADLs with minimal or no assistance
• Decrease the work of breathing.

7
Rationale

• You tell me the Rationale

8
Interventions

• Monitor pain and give analgesics q4h and prn as
  ordered by MD
• Monitor spirometry for increases in lung capacity
• Decrease assistance with ADLs as stamina
  increases
• Ambulate patient BID as ordered by MD