Student Name: _____ Date: 8/6/2014__ Patient’s Initials: L.A._ Age: 78_ Medical Diagnosis: _Admitted with CHF and SOA________

Subjective Data: 1. Pt. states, ”I can’t get my breath”.Objective Data (Head to Toe Assessment including Vital Signs): 1. Respiratory rate 32, B/P 102/60, Temp 101.0, AHR 104. 2. Oxygen saturation 88% on room air. 3. BLE crackles 4. Accessory muscle use. | Nursing Diagnosis: Breathing Pattern, Ineffective | Patient Goals/Objectives (What do you hope will be the result of your efforts? Make sure goal is patient oriented, measurable, and has a time frame). | Planned Interventions: (What is indicated for the management of this particular problem? Name three priority interventions making at least one patient teaching). | Rationale: (Why/How does the intervention work?) Cite page number and source for each intervention. | Evaluation of Patient Goals:(Was patient’s goal met/ not met/ ongoing? Why/why not? List evaluation criteria. If intervention is ongoing, list what patient has accomplished. | Short Term: Within three days: 1. Patient will state relief of SOA. 2. RR will return to within normal limits of 12 to 18 rpm. 3. Oxygen saturation will return to normal expected range of greater than or equal to 90% on room air | 1. Place patient on O2 @ 2lpm/nc. 2. Place patient on oxygen saturation 3. CXR 4. Teach patient to use the incentive spirometer to increase available lung capacity. | 1. This will increase the available oxygen in the patient’s blood. 2. This will monitor the amount of oxygen within the red blood cells within the patient’s blood. 3. This will assist in determining the effects of the fluid present in the patient’s lungs. 4. This will increase the patient’s available lung capacity and enable patient to be involved in his own care. | 1. Goal met: Patient state’s, “I can breathe so much better now”. 2. Goal met: Respirations are now 18. 3. Goal met: Oxygen saturation now 94% on room air. | Long Term: Will remain free of complaints of SOA for three months AEB: 1. Pt will be able to maintain respiratory homeostasis. 2. No accessory muscle use | 1. Patient will follow all discharge instructions 2. Patient will see PCP within two weeks of hospital discharge 3. Patient will notify PCP of any SOA | 1. Following physician instructions will enhance patient’s outcome. 2. Following up with patient’s PCP will improve patient care thus improve patient outcomes. 3. This will break the cycle of CHF exacerbation. | 1. Goal met: Pt experienced no episodes of SOA. 2. Goal met: No accessory muscle use. | Subjective Data: 1. Patient states, “my private area is really red and burns like fire when I clean it, or go to the bathroom”.Objective Data: 1. Perineal area is red and excoriated. No open areas, drainage or infection found. | Nursing Diagnosis: Impaired Skin Integrity | Patient Goals/Objectives (What do you hope will be the result of your efforts? Make sure goal is patient oriented, measurable, and has a time frame). | Planned Interventions: (What is indicated for the management of this particular problem? Name three priority interventions making at least one with patient teaching). | Rationale: (Why/How does the intervention work?) Cite page number and source for each intervention. | Evaluation of Patient Goals:(Was patient’s goal met/ not met/ ongoing? Why/why not? List evaluation criteria. If intervention is ongoing, list what patient has accomplished. | Short Term Goal: Three days. 1. Patient’s skin will remain the same or improve AEB reduced redness and pain. 2. Patient states improvement. | 1. Skin will be cleansed with soap and water and patted dry thoroughly after each incontinent episode and BID. 2. Physician prescribed protective cream will be applied after each cleansing. 3. Teach patient what measures to take if skin becomes red or irritated. | 1. Wet and or dirty skin will breakdown much quicker due to bacteria presence in a moist environment. 2. The protective cream prevents moisture and bacteria from irritating skin during the healing process. | 1. Goal Met: Patient’s skin redness and pain improved AEB patient statements. | Long Term Goal: Three months. 1. Patient’s skin will remain pink and blanchable. | 1. Pt will monitor skin daily and practice appropriate perineal hygiene daily. | 1. Knowledge of proper skin monitoring and care will enable patient to be an important part of his own patient care. | 1. Goal Met: Patient had no further problems with his perineal skin. |
References (Use your textbook or any other reputable source. Wikipedia is not a reputable source. Cite your references in APA format):

1. Ackley, B.J., Ladwig, G.B. (2013). Nursing diagnosis handbook: evidence- based guide to planning care.