NR 226 Week 4 Three Problem Nursing Care Plan Example

Care Plan: Three Problems for an 81-Year-Old Man on Day Three of Pneumonia, Each With a Goal That Could Come Out False by the End of the Shift

Student Name

College of Nursing, Chamberlain University

NR 226: Fundamentals: Patient Care

Instructor Name

Month Day, Year

Care Plan: Three Problems for an 81-Year-Old Man on Day Three of Pneumonia, Each With a Goal That Could Come Out False by the End of the Shift

Few Problems, Ranked and Defended

This plan carries three of the five diagnoses written last week for Mr. W., whose pneumonia is now in its third day of antibiotics: ineffective airway clearance, impaired skin integrity and risk for falls. The other two, the nutritional and fluid deficits, are folded into the skin problem, because the interventions that improve his intake are the same ones that help the sacral wound heal, and a separate plan for each would repeat itself.

Airway clearance is first because it can change fastest and because his fatigue, which drives the other problems, comes largely from the work of breathing with secretions he cannot clear. Skin is second because the injury exists and will deepen within hours if pressure is not relieved. Falls is third in the list but is flagged first in every spoken handover, because a fall can happen in one moment and he got up alone last night.

Problem 1: Ineffective Airway Clearance

Goal: by 1500 today, Mr. W. will cough up secretions at least once with each deep-breathing session, and his respiratory rate will be 22 or below with oxygen saturation 92% or above on no more than 2 L.

Interventions and rationale: Sit him upright, at least 45 degrees, for meals and for 30 minutes after, and in the chair twice today, because an upright chest lets the lungs expand and makes coughing more effective. Coach deep breathing and coughing every two hours while awake: three slow deep breaths, then a cough with a pillow hugged to his chest, because a weak cough is the cause named in the diagnosis and practice makes it more effective. Offer 120 mL of fluid each hour while awake, because his secretions are thick and he is dry, and thinner secretions are easier to cough up. Listen to his lungs before and after each session, because the change in crackles is the evidence of whether the coughing is working.

Evaluation, written forward: at 1500, count his respiratory rate for a full minute, check his saturation and oxygen flow, and ask him to cough; if the goal is not met, report to the provider with the numbers and the breath sounds.

Problem 2: Impaired Skin Integrity

Goal: by the end of the shift, the sacral wound will be no larger than 2 by 3 centimeters, with no new areas of redness that fail to fade within 30 minutes of pressure relief on his heels, hips or sacrum; and he will have eaten at least half of lunch and dinner and drunk at least 1,000 mL by 1900.

Interventions and rationale: Turn him every two hours, using a 30-degree side-lying tilt with pillows behind his back and between his knees, and keep him off his back as much as possible, because pressure over the sacrum is the cause named in the diagnosis. The evidence on the best interval is uncertain (Gillespie et al., 2020), so the unit's two-hour schedule is kept for a patient who already has an injury. Float his heels on a pillow. Ask the dietitian today about foods that taste better when food tastes metallic, such as cold foods or foods with lemon, and offer small meals after rest rather than straight after physical therapy, because altered taste and fatigue are the causes named for his poor intake.

Evaluation, written forward: at the 1500 turn, measure the wound and check the other pressure points; record meal percentages and fluid totals by 1900.

Problem 3: Risk for Falls

Goal: Mr. W. will not fall this shift and will use his call light each time he needs to get up, as recorded by the nurse or assistant who responds.

Interventions and rationale: Before each departure from the room, place the call light in his hand and ask him to show where it is, because his main risk factor is getting up alone. Tell him, in plain words, "Please call us every time you want to get up. It is not a bother. It is what we are here for," and repeat it on each shift, because his reluctance to call is the risk factor nursing can change. Offer the bathroom every two hours while awake and before he sleeps, because half of hospital falls in one large study were related to going to the bathroom (Hitcho et al., 2004). Keep the bed low with the brakes on, and put nonslip socks on him. Request a physical therapy walker assessment today, because he has no walker and his gait is unsteady.

Evaluation, written forward: at the end of the shift, record whether he fell and how many times he called before getting up.

Who Does Each Part

A plan is only as good as the people carrying it out, so each intervention has an owner. The nursing assistant turns him every two hours, offers the bathroom and fluids on the same round, and records meal percentages and fluid intake, with instructions to tell the nurse at once if he coughs up anything bloody, if his breathing looks harder, or if he tries to get up alone. The nurse does the deep-breathing coaching, listens to his lungs before and after, measures the wound at the 1500 turn, and makes the calls to the dietitian and physical therapy. His wife, who visits from noon to 1600, has offered to sit with him at lunch and encourage him to eat; she has been shown how to help him sit up safely and asked not to help him walk until physical therapy has seen him.

The two-hour round links three of the interventions on purpose. Turning, offering the bathroom and offering fluids happen together, so that a single visit relieves pressure, reduces the chance he gets up alone, and adds to his fluid total. Spreading them across separate rounds would triple the interruptions to his rest, which he needs as much as any of them.

Nothing That Was Not Assessed

The plan contains nothing that the assessment did not support. It does not address his possible nighttime confusion, because the evidence for it was too thin to write a diagnosis, although the night nurse is asked to screen him and report. It does not plan for his discharge home, because that depends on how his breathing and strength progress, and on his wife's mobility, which will be assessed later in the week. A plan that tried to address everything would have produced interventions without evidence behind them.

References

Gillespie, B. M., Walker, R. M., Latimer, S. L., Thalib, L., Whitty, J. A., McInnes, E., & Chaboyer, W. P. (2020). Repositioning for pressure injury prevention in adults. Cochrane Database of Systematic Reviews, (6), Article CD009958. https://doi.org/10.1002/14651858.CD009958.pub3

Hitcho, E. B., Krauss, M. J., Birge, S., Dunagan, W. C., Fischer, I., Johnson, S., Nast, P. A., Costantinou, E., & Fraser, V. J. (2004). Characteristics and circumstances of falls in a hospital setting: A prospective analysis. Journal of General Internal Medicine, 19(7), 732-739. https://doi.org/10.1111/j.1525-1497.2004.30387.x