Student Name: Gloria Gonzalez
Client Initials: T. L. Age: 79
DATA COLLECTION
SUBJECTIVE: (What is said by client, facts)
-Complained of shortness of breath
- Shallow breathing (sighness)
- Pain in chest area
GOAL AND OUTCOMES
GOAL: (Realistic for client and a SHORT
TERM goal and TIMED)
- Patient performing ADL without exacerbate
breathing patterns/ increasing pulse oximetry
level
OUTCOMES: (Use measurable and
observable terms)
1. Pulse oximetry is at 90 or improved after ADL
Potter, P.A. & Perry, A.G. (2009). Fundamentals of Nursing 7th ed. St. Louis, Missouri: Elsevier.
Clinical Site:
Sex: M Diet: 1600 calorie
Diabetic diet
OBJECTIVE: (Data that is measurable or
observable, from history, physical assessment,
lab results, test results, and medications)
-82 SpO2 with 3L of O2 via nasal cannula
- Respiratory rate at 18 with irregular breating
patterns
- History of lung cancer
- Left upper lobectomy 3/23/2011
- Spirometer out of range
- Chest tubes to drain fluids from lungs
PLANNING
IMPLEMENTATION/ NURSING ACTION
(Highlight nursing orders actually performed)
NURSING OBSERVATIONS (What will you
monitor assess, or reassess):
- Use pulse oximetry to monitor oxygen
saturation
- Assess skin color for development of cyanosis
- Monitor vital signs
- Assess lung sounds
- Assess respirations
NURSING INTERVENTIONS: (dependent,
independent)
- Maintain oxygen administration device as
ordered, attempting to maintain oxygen
saturation at 90% or greater
- Position with proper body alignment
- Encourage deep breathing, using spirometer
- Encourage or assist with ambulation
CLIENT OR FAMILY TEACHING:
- Explain the type of oxygen therapy being used
and why its maintenance is important
Date Submitted: 4/5/2011 NURS 2413 Basic Skills of Nursing
Clinical Week: 2nd week Admitting Diagnosis: Squamous Lung Cell
Carcinoma
THEORIST NURSING DIAGNOSIS
(Discuss as it applies to your client)
NURSING: Henderson- 1955
1. NANDA LABEL (actual or potential)
- “ Work independently with other health care
workers, assisting client in gaining independence - Impaired gas exchange
as quickly as possible; to help client gain lacking - Risk for activity intolerance
strength” (Potter and Perry, pp.49). - Constipation
- Clients current needs: RELATED TO
• breathe - Insufficient oxygen intake
• move - Abnormal breathing patterns
• eliminate wastes
AS EVIDENCE BY: (casual factors must be
amendable to nursing interventions)
- Shallow breathing
- Pulse oximetry
RATIONALE AND REFERENCES EVALUATION
Goal Met - Partially Met - Not Met
(Principles of nursing interventions are explained GOAL: _________MET_______________(reassess
scientifically, and supports each order identified each outcome criteria identified under goal)
and provides source used) WHY!
-Maintaining oxygen administration provides for 1. ADL were performed without interference of oxygen
adequate oxygenation saturation (95)kept at a stable breathing pattern
- Proper positioning promotes lung expansion
and improves air exchange
- Encouraging deep breathing will assist with
lung expansion
- Assistance with ambulation promotes lung
expansion, facilitates secretion clearance, and
stimulates deep breathing
Definition of the Medical Diagnosis:

Signs and Symptoms Associated with Condition: complained shortness of breath, shallow breathing

List ALL Diagnostic Test Results Identify ALL Medication (Include IV solutions and any PRN’s for the assigned client)
Lab or Results Rationale for MD orders Medication Classification Action Dosage Rationale Adverse Reactions Major Nursing
Imaging (Normal / related to client’s (Relate to (List Most Implication
Abnormal) diagnosis client’s Common)
condition)

Potassium Normal Improves blood flow Aspirin Nonopioid Prevention of 81mg/ 1tab Hx of open heart Nausea, Rash, Pain, Fever, Hepatic
Acetylsalicylic analgesic recurrent MI Daily surgery Vomiting studies, Renal
acid studies, Blood studies

Hemoglobin Abnormal Oxygen level Docusate Prevention of 100mg/ 1cap Excessive bowel Cramping, rectal
Sodium Stool softener dry, hard q12hrs Constipation activity, bleeding, vomitting
Dulcolax Stool stools Abdominal cramping
Softener
H2-histamine Decrease H2 Histamine Short term Dizziness, Blood count test
Hematocrit Abnormal Blood consisting red blood Famotidine receptor gastric Receptor, treatment of active constipation (look for decreasing
cell count Pepcid antagonist secretion Antagonist duodenal ulcer pneumonia platelets)

Lymphocyte Abnormal Immune responses Milk of Antacid/Laxative Relieve of 30mL U/D Constipation Hypotension, Weight, electrolyte
Magnesia susp indigestion Daily Respiratory balance, rashes
and heartburn depression

WBC Abnormal Blood consisting of white Triamterene Potassium- Edema 25mg/ 1cap Constipation Hypotension, Weight, electrolyte
blood cells Dyrenium sparing diuretic Daily Fatigue, balance, rashes
Hyperuricemia
Disorientation, Rash,
Sodium Abnormal Balance of electrolytes Acetaminophen Nonpioid, Block pait 500mg Pain Urticaria, Hepatic studies renal
Tylenol Analgesic impulses 1000mg/2tab Gastrointestinal blood & input, output
Antipyretic PRN hemorrhage ratio
Control
Calcium Normal Help blood vessels and Simvastatin Antilipidemic elevated 20mg/ 1tab High Cholesterol Upper respiratory 12hr fasting lipid
muscles contract Zocor cholesterol Bedtime levels infection, flatulence, profile
levels constipation Hepatic studies

RBC Abnormal Blood consisting of red Ondansetron Antiemetic Prevention of 4mg/ 2mL Prior to induction Headache, Absence of nausea,
blood cells Zofran nausea Q8hrs of ansethesia constipation, hypersensitivity
PRN diarrhea reaction

Glucose Abnormal Diabetic glyBuride Antidiabetic To drop 5mg/ 1tab Increase fluid Hypoglycemia, Hypo/hyperglycemic
glucose levels TID retention heartburn, nausea reaction, blood
glucose
20units/ Hypoglycemia,
Chloride Normal Balance of electrolytes Levemir Insulin detemir Insulin 0.2mL Diabetic insulin resistance,
Flexpen Bedtime hypokalemia
Monitor temperature,
BUN Normal Edema/ CHF Dextrose Caloric, Increases 25gm/ 50mL Diabetics Hypovolemia, electrolytes (K, Na,
Glucose parenteral intake of PRN hyperosmolarity, Ca, Cl, Mg) balance,
solution calories phlebitis blood glucose
Potter, P.A. & Perry, A.G. (2009). Fundamentals of Nursing 7th ed. St. Louis, Missouri: Elsevier.