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BOX 13—4 Benefits of the Nursing Interventions Classification

■ Helps demonstrate the impact that nurses have on the health care de-
livery system.
■ Standardizes and defines the knowledge base for nursing curricula
and practice.
■ Facilitates the appropriate selection of a nursing intervention.
■ Facilitates communication of nursing treatments to other nurses and
other providers.
■ Enables researchers to examine the effectiveness and cost of nursing
care.
Note: From Nursing Interventions Classification (NIC) 4th ed. (p. vi), by J. C. Dochterman and G. M. Bulechek, Eds., 2004, St. Louis, MO: Mosby. Reprinted with permission.
■ Assists educators to develop curricula that better articulate with clini-
cal practice.
■ Facilitates the teaching of clinical decision making to novice nurses.
■ Assists administrators in planning more effectively for staff and equip-
ment needs.
■ Promotes the development of a reimbursement system for nursing
services.
■ Facilitates the development and use of nursing information systems.
■ Communicates the nature of nursing to the public.

LIFESPAN CONSIDERATIONS Nursing Care Plan

ELDERS
When a client is in an extended care facility or a long-term care facility,
interventions and medications often remain the same day after day. It is
important to review the care plan on a regular basis, because changes in
the condition of elders may be subtle and go unnoticed. This applies to
both changes of improvement or deterioration. Either one should receive
attention so that appropriate revisions can be made in expected out-
comes and interventions. Outcomes need to be realistic with considera-
tion given to the client’s physical condition, emotional condition, support
systems, and mental status. Outcomes often have to be stated and ex-
pected to be completed in very small steps. For instance, a client who
has had a cerebrovascular accident may spend weeks learning to brush
her own teeth or dress herself. When these small steps are successfully
completed, it gives the client a sense of accomplishment and motivation
to continue working toward increasing self-care. This particular example
also demonstrates the need to work collaboratively with other depart-
ments, such as physical and occupational therapy, to develop the nurs-
ing care plan.

NURSING CARE PLAN Amanda Aquilini

NURSING DIAGNOSIS: Ineffective Airway Clearance Related to Viscous Secretions and Shallow Chest Expansion Secondary to
Deficient Fluid Volume, Pain, and Fatigue

DESIRED OUTCOMES*/
INDICATORS NURSING INTERVENTIONS
Respiratory Status: Gas exchange Monitor respiratory status q4h: rate,
[0402], as evidenced by depth, effort, skin color, mucous
■ Absence of pallor and cyanosis membranes, amount and color of
(skin and mucous mem- sputum.
branes) Monitor results of blood gases,
■ Use of correct chest x-ray studies, and incentive
breathing/coughing technique spirometer volume as available.
after instruction Monitor level of consciousness.
■ Productive cough Auscultate lungs q4h.
■ Symmetric chest excursion of Vital signs q4h (TPR, BP, pulse
at least 4 cm oximetry).
Within 48–72 hours
■ Lungs clear to auscultation Instruct in breathing and coughing
■ Respirations 12–22/min; techniques. Remind to perform,
pulse, 100 beats/min and assist q3h.
■ Inhales normal volume of air Administer prescribed expectorant;
on incentive spirometer schedule for maximum effective-
ness. Maintain Fowler’s or semi-
Fowler’s position.
Administer prescribed analgesics.
Notify physician if pain not relieved.
RATIONALE
To identify progress toward or deviations from goal. Ineffective
Airway Clearance leads to poor oxygenation, as evidenced by
pallor, cyanosis, lethargy, and drowsiness.
Inadequate oxygenation causes increased pulse rate. Respira-
tory rate may be decreased by narcotic analgesics. Shallow
breathing further compromises oxygenation.
To enable client to cough up secretions. May need encour-
agement and support because of fatigue and pain.
Helps loosen secretions so they can be coughed up and ex-
pelled.
Gravity allows for fuller lung expansion by decreasing pressure
of abdomen on diaphragm.
Controls pleuritic pain by blocking pain pathways and altering
perception of pain, enabling client to increase thoracic expan-
sion. Unrelieved pain may signal impending complication.

* The NOC # for desired outcomes are listed in brackets following the appropriate outcome. Outcomes, interventions, and activities selected are only a
sample of those suggested by NOC and NIC and should be further individualized for each client.

continued
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228 UNIT III / The Nursing Process

NURSING CARE PLAN Amanda Aquilini continued

DESIRED OUTCOMES*/
INDICATORS NURSING INTERVENTIONS
Administer oxygen by nasal cannula
as prescribed. Provide portable oxy-
gen if client goes off unit (e.g., for
x-ray examination).
Assist with postural drainage daily
at 0930.
Administer prescribed antibiotic to
maintain constant blood level.
Observe for rash and GI or other
side effects.
RATIONALE
Supplemental oxygen makes more oxygen available to the
cells, even though less air is being moved by the client,
thereby reducing the work of breathing.
Gravity facilitates movement of secretions upward through
the respiratory passage.
Resolves infection by bacteriostatic or bactericidal effect, de-
pending on type of antibiotic used. Constant level required to
prevent pathogens from multiplying.
Allergies to antibiotics are common.

NURSING DIAGNOSIS: Deficient Fluid Volume: Intake insufficient to replace fluid loss (See standardized care plan for
Deficient Fluid Volume, Figure 13-4).

NURSING DIAGNOSIS: Anxiety related to difficulty breathing and concern about work and parenting roles.

DESIRED OUTCOMES*/
INDICATORS NURSING INTERVENTIONS RATIONALE

Anxiety control [1402], as evi-
denced by
■ Listening to and following in-
structions for correct breathing
and coughing technique, even
during periods of dyspnea
■ Verbalizing understanding of
condition, diagnostic tests, and
treatments (by end of day)
■ Decrease in reports of fear and
anxiety
■ Voice steady, not shaky
■ Respiratory rate of 12–22/min
■ Freely expressing concerns and
possible solutions about work
and parenting roles Explore al-
ternatives as needed.
When client is dyspneic, stay with
her; reassure her you will stay.
Remain calm; appear confident.
Encourage slow, deep breathing.
When client is dyspneic, give brief
explanations of treatments and
procedures.
When acute episode is over, give
detailed information about nature
of condition, treatments, and tests.
As client can tolerate, encourage to
express and expand on her con-
cerns about her child and her work.
Presence of a competent caregiver reduces fear of being un-
able to breathe.
Control of anxiety will help client to maintain effective breath-
ing pattern.
Reassures client the nurse can help her.
Focusing on breathing may help client feel in control and de-
crease anxiety.
Anxiety and pain interfere with learning. Knowing what to ex-
pect reduces anxiety.
Awareness of source of anxiety enables client to gain control
over it. Husband’s continued absence would constitute a
defining characteristic for this nursing diagnosis.

Note whether husband returns as

scheduled. If not, institute care
plan for actual Interrupted Family
Processes

APPLYING CRITICAL THINKING

1. What assumptions does the nurse make when deciding that us- 4. Not every intervention has a time frame or interval specified. It
ing a standardized care plan for Deficient Fluid Volume is appro- may be implied. Under what circumstances is this acceptable
priate for this client? practice?
2. Identify an outcome in the care plan and its nursing intervention 5. In Table 13–1, Ineffective Airway Clearance is Amanda’s highest
that contribute to discharge care planning. What evidence sup- priority nursing diagnosis. Under what conditions might this diag-
ports your choice? nosis be of only moderate priority in Amanda’s case?
3. Consider how the nurse shares the development of the care
See Critical Thinking Possibilities in Appendix A.
plan and outcomes with the client.

* The NOC # for desired outcomes is listed in brackets following the appropriate outcome. Outcomes, interventions, and activities selected are only a
sample of those suggested by NOC and NIC and should be further individualized for each client.