Student Name Ray Velasco

Date

10/18/14
N256 Mini Care Plan

Expected
(complete before assessment)

Found
(complete after assessment)

1. Impaired gas exchange

1. Risk for impaired gas exchange

2. Risk for spread of infection

2. Imbalanced nutrition, less than body requires

3. Deficient knowledge

3. Deficient knowledge

Focus of physical
assessment

Respiratory and neuro

Respiratory and neuro

Need more
information from
patient/family/
doctor about:

History of present illness and events leading to

hospitalization.

Need more information on patients living situation

since he is about to get discharged soon. The patient is
a poor historian as he presents with dementia.

1. Maintain/improve respiratory function

1. Assess/Maintain/improve respiratory function

2. Administer medications on schedule

2. Administer antibiotics on schedule to maintain

3. Inform patient of condition and treatment

therapeutic levels.

Nursing
Diagnoses
(NANDA)

Top three
priorities (goals)
for patient care

3. Encourage coughing and deep breathing exercises

Nursing
Interventions

1. Monitor vital signs closely

1. Monitor vital signs closely

2.Auscultate lung fields, noting decreased/absent

2. Auscultate lung fields, noting decreased/absent

airflow

airflow

3. Administer antibiotics on schedule

3. Administer antibiotics on schedule

4. Encourage coughing and deep breathing

4. Encourage coughing and deep breathing exercises

exercises.

and OOB

5. Suction as needed

5. Encouraged adequate calorie/nutrients intake to

facilitate healing.

Teaching
needed/provided

Encourage coughing and deep breathing

exercises.
Keep HOB up at least 30 degrees.

Patient was encouraged to cough and deep breathe at

least once an hour. The patient was educated on the
disease process and the significance of the
aforementioned exercises in improving/preventing
pneumonia.

Discharge
planning

The patient may need assistance at home given

his age and medical conditions.

The patient needs assistance from a social worker or a

case manager. He may need home health care to help

with ADLs. The patient may not be able to maintain

medication schedule and appointments. He also needs
frequent reminders to cough and deep breath due to
his dementia.