ASSESSMENT* ANALYSIS* PLAN IMPLEMENTATION EVALUATION of RETHINK REPLAN REDO

DATA BASE sorted Statement CLIENT (NURSING ACTIONS, including teaching) STG/LTG GOALS REWRITE the Implementations and
& grouped for Short term Goal RATIONALE AND EACH tell if will keep in POC, Revise it, or
EACH nursing 3 part NANDA Long term Goal NUMBER THEM Nursing ACTION Delete. Tell who will do it.
diagnosis) NURSING IMPLEMENTATI This is like a shift report.
DIAGNOSIS ON
Have six of these CORRELATE
Can be either s or o Numbering
O Analysis: This is a 1. Assess respiratory rate, depth and ease of 1. Registered nurse continue to
Crackles on lung 75 year old female STG: The client respiration. R:Respiration exceeds 30 breaths/min, 1. ABG’s, O2 assess respiratory rate, depth and
fields dx aspiration will maintain a cardiovascular or respiratory alteration exists. ease of respiration.
sats WNL.
pneumonia and with normal ABG’s 2. Auscultate breath sounds every 1 to 2 hours. R: 2. Registered nurse continue to
O a tracheostomy. and O2 sats Crackles may alert the nurse for airway obstruction. STG met. auscultate breath sounds every 1 to 2
Skin color pale during shift 3. Assess for cyanosis of the skin. R: Central hours.
cyanosis of the tongue and oral mucosa is 2. LTG unable 3. Registered nurse continue to
O LTG: The client indicative of hypoxia. to evaluate this assess for cyanosis of the skin. 4.
ph 7.56 Impaired gas will be weaned 4. Position the client in a semirecumbent position Position the client in a
with the HOB at 30 to 45 degree angle. R: To time
exchange r/t off the vent and semirecumbent position with the
O ventilation- able to maintain decrease aspiration of gastric, oral and nasal HOB at 30 to 45 degree angle.
HCO3 36.4 mEq/L perfusion imbalance O2 sats above secretions. 5. Registered nurse continue to
AEB abnormal 97% room air 5. Suction tracheobronchial secretions PRN. R: suction tracheobronchial secretions
O arterial blood gases before discharge Retention of secretions leads to hypoxia and PRN.
PaO2 56.7 mm Hg from unit. promote infection. 6. Registered nurse continue to
6. Monitor O2 saturation. R: O2 sat less than 90% monitor O2 saturation
O indicates oxygenation problems. 7. Registered nurse continue to teach
SpO2 88% 7. Teach the client about energy conservation. R: the client about energy conservation.
Alternating rest periods with activity is helpful to
8. Registered nurse continue to teach
improve respiratory function.
the client about identifying and
8. Teach the client about identifying and avoiding
avoiding situations that exacerbates
situations that exacerbates impairment of gas
impairment of gas exchange.
exchange. R: Irritants decrease the client’s
9. Registered nurse continue to teach
effectiveness in accessing oxygen during
the client and family to keep
breathing.
temperature above 68F and to avoid
9. Teach the client and family to keep temperature
above 68F and to avoid cold weather. R: Cold air
cold weather.
temperatures causes constriction of the blood
vessels, which impairs the client’s ability to absorb
oxygen.