Care Plan Assistance

[Azure1213]

So I'm wondering if this care plan (so far) is realistic? We did not have clinical this week so my instructer created a teaching template regarding knowledge deficit. The client is a post-op TKA.

Activity Intolerance RT knowledge defict: coughing and deep breathing AEB shortness of breath when walking.

Goal: PT will have activity tolerance by Feb. 5

Client outcomes:

1. The PT will verbalize need for coughing and deep breathing

2. The client will learn how to cough and deep breathe

3.The client will identify factors that increase activity intolerance

4. The client have report having decreased shortness of breath

5. The client will ambulate down the hall 20 ft. 3x a day.

Nursing Interventions:

1.nurse will asses pts need to learn

2. The nurse will teach the client how to cough and deep breathe

3. The nurse will help the client identify factors that cause activity intolerance

4. The nurse will monitor the client's breathing patterns for shortness of breath

5. The client will ambulate down the hall 20 ft. 3x a day.

I'm asking if these goals and the diagnosis r realistic and can be done.

[Azure1213]

i redid my plan to make it more realistic. i changed it to:

ineffective airway clearence r/t knowledge deficit: coughing and deep breathing exercises aeb inability to clear airway secretions by having crackles in the lungs

goal patient will have a an effective airway clearance by feb. 3

outcome: pt will:

1. verbalize the need for coughing and deep breathing

2. demonstrate by being able to cough and deep breathe

3. the client will have effective airway clearance in lungs by being free of crackles in the lungs

interventions

nurse will:

1. assess the pt’s motivation to learn.

2. teach the client how to cough and deep breathe

3. the nurse will elevate client’s hob at 45 degrees to encourage draining and nurse will assess lung sounds every four hours

***note these interventions will be what i refer to as “generic intervention” and should be included in your actual teaching plans.

rationale

1. motivation influences how quickly and how much a person learns and is generally greatest when a person recognizes a need and believes the need will be met through learning. (kozier, 445)

2. coughing and deep breathing help reduce secretions in the airway (kozier 1368) .

3. sitting up will drain respiratory secretions and monitoring the client’s lungs for crackles every 4 will signify reduction(source).

evaluation

goal not met. the client was not able to verbalize the need for coughing and deep breathing because they were not willing to learn. when the nurse tried to teach the client how to cough and deep breathe, pt threw water pitcher at nurse and told her to get out. pt also refused to allow nurse to raise head of bed. upon assessment of client’s lungs, crackles were worse. client’s daughter was notified of client’s unwillingness to learn and she agreed to talk to client. will evaluate at end of shift to tailor to client’s needs.