Nursing Care Plan

1. Priority Nursing Diagnosis Written in three-part statement (Diagnosis XXX, related to XXX, as evidenced by XXX) *Risk Diagnoses NEVER go in this section.*

2. Planning (outcome/goal) Measurable goal during your shift (at least 1 per Nursing Diagnosis) *Think SMART GOAL*

3. Prioritized Independent and collaborative nursing interventions; include further assessment, intervention and teaching (at least 4 per goal)

4. Rationale for each intervention must be supported with Evidence Based Citations

5. Evaluation Goal Met, Partially Met, or Not Met & Explanation

YOU CANNOT USE THESE DIAGNOSIS BECAUSE MY GROUP MEMBERS ALREADY USED THEM AND WE ALL HAVE TO HAVE DIFFERENT ONES!!
– Ineffective peripheral perfusion related to pneumonia as evidenced by oxygen saturation of 86%
-Sleep deprivation related to pneumonia as evidence by short of breath and productive cough at night
-Impaired gas exchange related to shortness of breath as evidenced by O2 sats of 87% on room air.
– Ineffective thermoregulation related to the infectious process of bacterial pneumonia as evidenced by temperature of 102F, shortness of breath, and tachypnea.
-Activity Intolerance related to compromised oxygen transport system secondary to COPD
-Ineffective breathing pattern related to decreased lung expansion.

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