Critique Me! Nursing Care Plans

  1. 0
    Hey guys, its that time again....nursing care plan for clinical are due I have put together two care plans and would appreciate a critique or suggestions of what I could do better. The two I have put together are for a 91 yo Male recently diagnosed with CHF who was admitted to my floor with Dyspnea and CHF.


    #1 Priority Nursing Diagnosis: Decreased Cardiac Output
    Related to: alterations in preload, afterload, and myocardial contractility associated with the cardiac condition causing the heart to fail.
    As evidenced by:
    Subjective data: The nursing home staff reported the patient was SOB and confused. The patient stated upon admission that he had CHF. He also informed the admissions nurse that he was on oxygen at home.
    Objective data: Elevated BUN 34; Elevated Creatinine 2.1; Increased BNP indicative of CHF 17,772; Stage II pressure ulcer on the left heel and a stage III pressure ulcer on the coccyx; Decreased H&H 10 and 32; Decreased Albumin 1.6; The patient did not move from the bed during my time with him; He had to be changed 2x because he was unable to get up and go to the restroom. The patient received 4LO2 via NC;




    Nursing Outcome
    (2 outcomes that are pt objective, measurable and time defined)
    Nursing Intervention (NIC)
    (At least three interventions/outcome)
    Scientific Rationales for Interventions Evaluation of Outcome
    1. The client will demonstrate adequate cardiac output as evidenced by blood pressure, pulse rate, and rhythm within normal limits for the client; maintain strong peripheral pulses throughout the shift on 03.11.2013.





    1. Monitor I & O 3x a day 0700-1400, 1400-2100, 2100-0700.
    2. Assess the client for signs of decreased cardiac output; listen to heart sounds, lung sounds, JVD, BP, HR.
    3. Monitor the BUN, Creatinine, BNP, and potassium.


    1. Decreased cardiac output results in decreased perfusion of the kidneys, with a resulting decrease in urine output.
    2. These things are criteria for diagnosing and monitoring HF.
    3. Monitoring potassium and kidney function are essential to minimize the potential for life-threatening hyperkalemia that can occur from renal insufficiency, advanced age, and advanced heart failure. BNP monitors for how far HF has advanced.
    1. The client’s BP was within his normal at 124/67. Pulse remained within normal for the client at 92. Peripheral pedal pulses were +2 and radial pulses were +2. No JVD noted. BUN and Creatinine remained elevated and the potassium level was low. The outcome was met.
    1. The client will have improved cardiac output as evidenced by unlabored respirations 15-20/min; no change in mental status during the shift on 03.11.2013.


    1. Assess the client’s respiratory status q2hr.
    2. Administer IV fluids as ordered and observe for s/s of fluid overload.
    3. Place the patient in Fowler’s or semi-Fowler’s position.
    1. A change in respiratory status may indicate further complications of the client’s HF.
    2. In the client with decreased cardiac output, poorly functioning ventricles may not tolerate increased fluid volume.
    3. This position may decrease the WOB and may also decrease venous return and preload.
    1. The client continued to have respirations of 17/min with 4L O2 via NC. His mental status did not deteriorate during my time with him. The outcome was met.






    NURSING CARE PLAN #2Nursing Diagnosis


    #2 Priority Nursing Diagnosis: Impaired Gas Exchange
    Related to: Cardiopulmonary dysfunction secondary to a cardiac condition causing the heart to fail
    As evidenced by:
    Subjective data:The nursing home staff stated that the client was confused and SOB. They also stated that he may have aspirated something while eating. The client stated that he was SOB.
    Objective data: The client is on O2 in the nursing home. Hx of chronic intermittent hypoxia, asthma, CHF, and pneumonia. The client has bibasilar rales and bilaterial rhonchi. X-ray of the chest shows pulmonary venous congestion that indicates there is pulmonary edema. HR 92. Respiratory rate 18/min. O2 95.




    Nursing Outcome
    (2 outcomes that are pt objective, measurable and time defined)
    Nursing Intervention (NIC)
    (At least three interventions/outcome)
    Scientific Rationales for Interventions Evaluation of Outcome
    1. The client will maintain adequate oxygenation as evidenced by a pulse oximetry reading greater than 90% on 03.11.2013
    1. Monitor the client’s oxygen saturation q2hr by pulse oximetry.
    2. Position the client in semi-Fowler’s.
    3. Maintain low-flow oxygen therapy; 4L via NC.
    1. An oxygen saturation of less than 90% indicates significant oxygenation problems.
    2. Being in a semi-Fowlers position increases oxygenation and ventilation.
    3. Low-flow oxygenation helps to prevent hypoxemia




    1. The client will maintain a normal respiratory rate and rhythm; lung sounds will be clear during the shift on 03.11.2013.
    1. Monitor respiratory rate, depth, and effort.
    2. Monitor client’s behavior and mental status.
    3. Administer the client’s Levalbuterol (Xopenex) 1.25mg q4hr as ordered.
    1. Normal respirations in an adult are 15-20 breathes/min. Less than 15 breathes/min indicates respiratory distress.
    2. Changes in behavior and mental status can be early signs of further impaired gas exchange.
    3. Levalbuterol is a bronchodilator. It helps to decrease resistance in the bronchi and bronchioles in order to increase airflow to the lungs.








  2. 5 Comments so far...

  3. 1
    A quick glance.....it's very good...I'll be back in a few!
    mrsamjones likes this.
  4. 1
    I know it is a really long post but I appreciate the time you are taking out to critique it! Thanks!
    Esme12 likes this.
  5. 1
    A few problems I see right off the bat:

    #1 Priority Nursing Diagnosis: Decreased Cardiac Output
    Related to: alterations in preload, afterload, and myocardial contractility associated with the cardiac condition causing the heart to fail.
    As evidenced by:
    Subjective data: The nursing home staff reported the patient was SOB and confused. The patient stated upon admission that he had CHF. He also informed the admissions nurse that he was on oxygen at home.
    Objective data: Elevated BUN 34; Elevated Creatinine 2.1; Increased BNP indicative of CHF 17,772; Stage II pressure ulcer on the left heel and a stage III pressure ulcer on the coccyx; Decreased H&H 10 and 32; Decreased Albumin 1.6; The patient did not move from the bed during my time with him; He had to be changed 2x because he was unable to get up and go to the restroom. The patient received 4LO2 via NC;
    I don't see one of your objective data to support this nursing diagnosis on the list of defining characteristics for the diagnosis. Not one. I'm not saying this patient doesn't have decreased CO-- he probably does-- but to make a nursing diagnosis you must, must identify defining characteristics in your assessment. Extraneous data do not belong in a diagnostic statement.

    Nursing Outcome
    (2 outcomes that are pt objective, measurable and time defined)
    Nursing Intervention (NIC)
    (At least three interventions/outcome)
    Scientific Rationales for Interventions Evaluation of Outcome
    1. The client will demonstrate adequate cardiac output as evidenced by blood pressure, pulse rate, and rhythm within normal limits for the client; maintain strong peripheral pulses throughout the shift on 03.11.2013.






    1. Monitor I & O 3x a day 0700-1400, 1400-2100, 2100-0700.
    2. Assess the client for signs of decreased cardiac output; listen to heart sounds, lung sounds, JVD, BP, HR.
    3. Monitor the BUN, Creatinine, BNP, and potassium.



    1. Decreased cardiac output results in decreased perfusion of the kidneys, with a resulting decrease in urine output.
    2. These things are criteria for diagnosing and monitoring HF.
    3. Monitoring potassium and kidney function are essential to minimize the potential for life-threatening hyperkalemia that can occur from renal insufficiency, advanced age, and advanced heart failure. BNP monitors for how far HF has advanced.
    1. The client’s BP was within his normal at 124/67. Pulse remained within normal for the client at 92. Peripheral pedal pulses were +2 and radial pulses were +2. No JVD noted. BUN and Creatinine remained elevated and the potassium level was low. The outcome was met.
    1. The client will have improved cardiac output as evidenced by unlabored respirations 15-20/min; no change in mental status during the shift on 03.11.2013.



    1. Assess the client’s respiratory status q2hr.
    2. Administer IV fluids as ordered and observe for s/s of fluid overload.
    3. Place the patient in Fowler’s or semi-Fowler’s position.
    1. A change in respiratory status may indicate further complications of the client’s HF.
    2. In the client with decreased cardiac output, poorly functioning ventricles may not tolerate increased fluid volume.
    3. This position may decrease the WOB and may also decrease venous return and preload.
    1. The client continued to have respirations of 17/min with 4L O2via NC. His mental status did not deteriorate during my time with him. The outcome was met.




    These outcomes are not related to nursing interventions. Most are results of medical plan of care-- medications, etc.
    "Assess/monitor" are not interventions. Assessments and monitoring lead to no changes, therefore it is not possible to say that because you do them, goals are met.
    Anytime you find yourself including "...as ordered" all you are doing is reiterating your legal responsibility to implement parts of the medical plan of care. The nursing plan of care should have nursing interventions -- and nursing interventions are, by definition, not merely doing what a physician tells you to do. And again, assessments do not play any part in change or maintenance of condition, so you cannot attribute met goals to them.

    You're close on the Fowler's/semiFowler's, but you don't relate it to your (so far unsupported) diagnosis of decreased cardiac output.





    #2 Priority Nursing Diagnosis: Impaired Gas Exchange
    Related to: Cardiopulmonary dysfunction secondary to a cardiac condition causing the heart to fail
    As evidenced by:
    Subjective data:The nursing home staff stated that the client was confused and SOB. They also stated that he may have aspirated something while eating. The client stated that he was SOB.
    Objective data: The client is on O2 in the nursing home. Hx of chronic intermittent hypoxia, asthma, CHF, and pneumonia. The client has bibasilar rales and bilaterial rhonchi. X-ray of the chest shows pulmonary venous congestion that indicates there is pulmonary edema. HR 92. Respiratory rate 18/min. O2 95.

    Again, "cardiopulmonary dysfunction secondary to a cardiac condition causing the heart to fail" is not an accepted related factor for this diagnosis. Your objective data include many things that are not defining characteristics for this nursing diagnosis; I encourage you to get your NANDA-I and look at page 214 for the defining characteristics and causes of this diagnosis. If you assessed any of them in this patient, this is the place to note them. Extraneous data are not needed.

    Nursing Outcome
    (2 outcomes that are pt objective, measurable and time defined)
    Nursing Intervention (NIC)
    (At least three interventions/outcome)
    Scientific Rationales for Interventions Evaluation of Outcome
    1. The client will maintain adequate oxygenation as evidenced by a pulse oximetry reading greater than 90% on 03.11.2013
    1. Monitor the client’s oxygen saturation q2hr by pulse oximetry.
    2. Position the client in semi-Fowler’s.
    3. Maintain low-flow oxygen therapy; 4L via NC.
    1. An oxygen saturation of less than 90% indicates significant oxygenation problems.
    2. Being in a semi-Fowlers position increases oxygenation and ventilation.
    3. Low-flow oxygenation helps to prevent hypoxemia



    1. The client will maintain a normal respiratory rate and rhythm; lung sounds will be clear during the shift on 03.11.2013.
    1. Monitor respiratory rate, depth, and effort.
    2. Monitor client’s behavior and mental status.
    3. Administer the client’s Levalbuterol (Xopenex) 1.25mg q4hr as ordered.
    1. Normal respirations in an adult are 15-20 breathes/min. Less than 15 breathes/min indicates respiratory distress.
    2. Changes in behavior and mental status can be early signs of further impaired gas exchange.
    3. Levalbuterol is a bronchodilator. It helps to decrease resistance in the bronchi and bronchioles in order to increase airflow to the lungs.
    Your initial data indicate that he had an SpO2 of 95%, so I can't see how this is part of this diagnosis. If there is no problem (as you define it) it's illogical to say you have met a goal to fix it (I see no outcomes on this part anyway). Also, again, monitoring and following physician plan of care is not evidence of any independent nursing assessment, judgment, or plan.

    I think you, like many students, are still thinking in terms of medical diagnoses and interventions. You are not using the nursing process to assess your patient and plan his nursing care. It is easy to think that the true statements you put in for rationales have anything to do with what your nursing assessments and plan of care are; they have to do with his condition, but since you don't have defining characteristics for any nursing diagnoses, they don't relate to your plan of nursing care.

    You MUST use nursing assessment of defining characteristics for nursing diagnoses, because once you have identified them, the path towards your nursing plan of care (as opposed to implementing a medical plan of care) will become clear to you. Think like a nurse.
    Last edit by GrnTea on Apr 14, '13
    pmabraham likes this.
  6. 0
    GrnTea beat me to it.....
    1 Priority Nursing Diagnosis: Decreased Cardiac Output
    Related to: alterations in preload, afterload, and myocardial contractility associated with the cardiac condition causing the heart to fail.
    As evidenced by:
    Subjective data: The nursing home staff reported the patient was SOB and confused. The patient stated upon admission that he had CHF. He also informed the admissions nurse that he was on oxygen at home.
    Objective data: Elevated BUN 34; Elevated Creatinine 2.1; Increased BNP indicative of CHF 17,772; Stage II pressure ulcer on the left heel and a stage III pressure ulcer on the coccyx; Decreased H&H 10 and 32; Decreased Albumin 1.6; The patient did not move from the bed during my time with him; He had to be changed 2x because he was unable to get up and go to the restroom. The patient received 4LO2 via NC;
    I highlighted the only objective data that really addressed your diagnosis.

    NANDA I defines decreased cardiac output as.....
    Inadequate volume of blood pumped by the heart per minute to meet metabolic demands of the body


    Defining Characteristics ...... AEB
    Altered Heart Rate/Rhythm: Arrhythmias; bradycardia; electrocardiographic changes; palpitations; tachycardia
    Altered Preload: Edema; decreased central venous pressure (CVP); decreased pulmonary artery wedge pressure (PAWP); fatigue; increased central venous pressure (CVP); increased pulmonary artery wedge pressure (PAWP); jugular vein distention; murmurs; weight gain
    Altered Afterload: Clammy skin; dyspnea; decreased peripheral pulses; decreased pulmonary vascular resistance (PVR); decreased systemic vascular resistance (SVR); increased pulmonary vascular resistance (PVR); increased systemic vascular resistance (SVR); oliguria, prolonged capillary refill; skin color changes; variations in blood pressure readings
    Altered Contractility: Crackles; cough; decreased ejection fraction; decreased left ventricular stroke work index (LVSWI); decreased stroke volume index (SVI); decreased cardiac index; decreased cardiac output; orthopnea; paroxysmal nocturnal dyspnea; S3 sounds; S4 sounds
    Behavioral/Emotional: Anxiety; restlessness, lethargy, weakness


    Related Factors (r/t)
    Altered heart rate; altered heart rhythm; altered stroke volume: altered preload, altered afterload, altered contractility
    Where in your assessment is your evidence for this patient that proves your statement? Stage II ulcer isn't proof of decreased cardiac output.....right?

    What signs did the patient have that made you believe this was important for him.
  7. 0
    NANDA describes impaired gas exchange as....
    Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane

    Defining Characteristics: Abnormal arterial blood gases; abnormal arterial pH; abnormal breathing (e.g., rate, rhythm, depth); abnormal skin color (e.g., pale, dusky); confusion; cyanosis; decreased carbon dioxide; diaphoresis; dyspnea; headache upon awakening; hypercapnia; hypoxemia; hypoxia; irritability; nasal flaring; restlessness, somnolence; tachycardia; visual disturbances


    Related Factors (r/t): Ventilation-perfusion imbalance; alveolar-capillary membrane changes
    Does your patient fit this picture? DO you have evidence to support your theory?
    As evidenced by:
    Subjective data:The nursing home staff stated that the client was confused and SOB. They also stated that he may have aspirated something while eating. The client stated that he was SOB.
    Objective data: The client is on O2 in the nursing home. Hx of chronic intermittent hypoxia, asthma, CHF, and pneumonia. The client has bibasilar rales and bilaterial rhonchi. X-ray of the chest shows pulmonary venous congestion that indicates there is pulmonary edema. HR 92. Respiratory rate 18/min. O2 95
    .


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