Question

Write a CARE PLAN - on patient with Asthma,

Pt. demographics ----- Pt. is always in Fetal position , has bil heel wounds and has seizure precautions, has a history of pneumonia, asthama, klebisella, malnutrition Pt. cannot verbalize anything. Pt. vitals - temp.- 98.0*F , pulse - 106, respirations - 18, bp- 133/66, spo2- 98 AAO x 0

Write a care plan - 3 Goals needed (long term and short term) 3 Nursing diagnosis with rationale 5 Nursing intervention for each Nursing Diagnosis

Answer 1

Goals:

Long term

• Prevent exacerbation of asthma or acute asthma attacks
• To maintain complete nutritional diet andcdtatus
• To make patient feel secured

Short term

• To prevent and reduce the pain discomforts due to wound
• To enhance wound healing and avoid infection
• To encourage patient to convey his needs

Nursing diagnosis

1.Ineffective breathing pattern related to bronchospasm as evidence by fetal position secondary to asthma

Nursing intervention and rationale

• Check vital signs ,it always gives base line data in planning and providing care
• Place patient in propped up position or semi Fowler or Fowler's position to increase the lung capacity and thus oxygenation
• Administration medication as per order to dilate constricted airway or its pathway
• Avoid triggers that may induce asthmatic attack which will result in seizure due to CNS disturbances
• Assess the patient to prevent respiratory complications

2.Impaired tissue integrity related to damage to integumentary system as evidenced by bilateral heel wound

Nursing intervention and rationale

• Assess the wound site daily for sign of infection (pain,redness,swelling, warmth) and to plan for care
• Administer medication as per order to prevent infection
• Maintain risk assessment tool in order to be aware of immobility related skin breakdown
• Provide a gel cushion or heel pad to reduce pressure
• Provide a rich protein diet to enhance wound healing

3.Risk for mobility related to body mechanics as evidenced by continuous fetal position

Nursing intervention and rationale

• Assess and treat the underlying cause (asthma) ,which leads to fetal position, which will enhance breathing and patient to change position
• Provide change of position to relieve pressure point causing ulcer
• Provide physiotherapy to enhance the musculoskeletal activities
• Provide foot rest to prevent foot drop
• Provide back massage to enhance circulation and comfort.