Nursing Care Plan2 - Baker College of Flint NURSING CARE...

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Baker College of Flint NURSING CARE PLAN Number: _1___ Client Initials: B.E. ________  Date of Care: 10-18-10/10-21-10 Student Name: Jennifer Franks Assessment Subjective/Objective Data Nursing Diagnosis Diagnosis and Defining Characteristics Goals &Expected Outcomes Long and Short Term Nursing Interventions (Student nurse will…) Scientific Rationale (ref. from nursing textbook )
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Subjective: (stated) B.E. stated "I became increasingly tired a couple weeks ago". "A few days later I couldn't even walk up my stairs". "Then several nights passed and on 10/18/10 I woke up at 4:00am not being able to breathe". Daughter, who's a nurse, noticed difficulty breathing and edema in feet. Objective: (observed /obtained) B.E. has history of atherosclerotic heart disease, mitral regurgitation, and paroxysmal atrial fibrillation. Upon admission, faint systolic murmur, fine crackles in base; more on left side. SpO2 was 88%. NC 2 lpm. Lab: RBC, Hgb, Hct, and Chloride all less than normal. CO2 higher than normal. Gordon’s Functional Health Pattern: Activity-Exercise Nursing Dx: (ref. from Ackley) Activity Intolerance
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