Nursing Care Plan Topic: Case History Past History Current StatusMr. Peterson is a 56-year-old male who is the Captain of Fire Department #32. As a result of the stressful nature of his job, Mr. Peterson has a habit of smoking 2 packs of cigarettes a day and has done so for the past 25 years. Mr. Peterson has 2 children, 1 of which is also in the fire department. He has recently celebrated his 25th anniversary with his wife and has 2 grandchildren.During the last few years, Mr. Peterson has experienced slight shortness of breath and a mild cough with activity and upon rising in the morning. Recently, Mr. Peterson has noticed that he has difficulty climbing stairs and performing his duties while out on fire calls, which not only produces fatigue but requires him to stop what he is doing to catch his breath. He has noticed being short of breath on exertion and experiencing dyspnea at rest. The only way he can sleep is if he is sitting up with the aid of several pillows. He has had an approximate weight loss of 13 pounds in the last 2 months. Mr. Peterson is brought into the Emergency Department by his wife for evaluation because of his increasing dyspnea.On assessment, Mr. Peterson looks thin and frail. He is restless and tachypneic and uses pursed-lip breathing. He is sitting on the side of his bed, leaning on an over-bed table. His vital signs are as follows: heart rate 120, respirations 30, blood pressure 140/80. Arterial blood gases indicate the following: PO2 39mmHg; PCO2 52mm Hg; pH 7.32; bicarbonate 36mEq/L. Auscultation of the lungs reveals decreased breath sounds to the bases bilaterally and expiratory wheezes. Mr. Peterson’s chest has an increased anterioposterior diameter and the accessory muscles are being used for ventilation. Mr. Peterson has been diagnosed with COPD. He is treated with a bronchodilator via a nebulizer and administered oxygen at 2L/min. NURSING CARE PLAN (FORMAT) Each student will develop a Nursing Care Plan (NCP) utilizing the nursing process in planning care as well as the incorporation of the Allen/McGill Nursing Model for holistic care while following the format provided. Care Plan Components:Client Demographics:Past Medical & Social HistoryFamily SituationClient’s Issues or Challenges (Actual / Potential)Medical DiagnosisSigns & SymptomsLab ValuesMedicationsClient StrengthsGrowth & Development Stage (according to Eric Erickson’s theory)Identification of pertinent assessment data to elicit.2 (Actual) Nursing Diagnosis1 (Potential / Risk) Nursing Diagnosis2 Goals for each Nursing Diagnosis1 – Short-term (Client-focused)1 – Long-term (Client-focused)2-3 Nursing Interventions for each Goal and Rationales1st Intervention should include assessing/assessment of the client for the specific issue.Include a rationale for each nursing intervention.Detail any client and family teaching related to the care plan.Evaluation for each GoalShould include a specific timeline mentioned in the evaluation. For e,example The client will demonstrate ……… by the end of the shift, every 15 minutes, every hour or by a specific date. Health Science Science Nursing NURS 461 Share QuestionEmailCopy link Comments (0)
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