Georgia Baptist College of Nursing
NR210: Nursing Care Plan
#5. Bova Tues. Meet back of classroom on the right.
Nursing Diagnosis: : Surgical recovery delayed (risk of) r/t pt’s refusal to follow postop regime AEB pt’s refusal to sit up or cough and his fear that “incision
will burst open”.
Client Goals with Nursing Interventions Rationales Evaluate
Valid The pt will cough Assess: 1. Respiratory excursion Pt coughs and
ation: and deep breath
Subje 1. Assess resp. excursion and should be symmetrical deep breathes
ctive effectively every
incision q2hr. without lag (Nursing effectively
Data: 2 hrs in 24 hours
Health Assessment, p. every 2 hrs.
(I added a time 2. Assess highest level of Spirometry 341).
frame) AEB: with one deep breath q4hr. Pt’s
2., 3., 5. Pt takes and holds respiratory
Increase Add……..Assess for s/s of fear/anxiety deep breath for a few excursion is
in re: the incision site. Need to add this seconds. Spirometry greater than
respirator to allow you to meet the outcome encourages deep 2cm.
y criteria of the goal.
Objec breathing. (Nursing care
excursion Pt verbalizes
tive Treat: Plans, p. 571).
Data: . lessened fear
3. Encourage pt to deep breathe 10 4., 6. Splinting the regarding
times every hr between 250-1000. incision eases the incision
Don’t use the term discomfort of coughing bursting open.
“encourage”…how will you and taking deep breaths
in fear of
encourage him? Give specifics. (Nursing Care Plans, p.
4. Teach pt to cough and deep breathe
with pillow in place. Good job!! Nice
5. . Teach pt how to use spirometer.
rationales. Be sure to use
6. Teach pt about incision. What APA format to cite your
about the incision…incision rationales.