What is the nursing care plan of the following scenario? Mr. Bryan L. was assessed and found to have the following signs and symptoms: awake, confused and agitated. He responds to your questions but sometimes he does not use appropriate terminology. He knows his name, but does not know he is in the hospital. He has productive cough, which he spits in the emesis basin. The sputum is thick and yellow, with streaks of blood. Mr. L. states, “I smoke 3 packs of cigarettes a day for many years and I’m going to keep on smoking!” Laboratory values reflect an elevated level of carbon dioxide in his blood. On minimal exertion, he is experiencing shortness of breath (dyspnea); respiratory rate is 29 breaths/min and uses his abdominal accessory muscles to breathe. Capillary refill is sluggish, greater than 3 seconds. Both of his hands and feet are pale and cold to touch. Assessment Diagnosis Goal/expected outcome Planning Intervention Rationale Evaluation Objective data: Subjective data:
What is the nursing care plan of the following scenario?
Mr. Bryan L. was assessed and found to have the following signs and symptoms: awake, confused and agitated. He responds to your questions but sometimes he does not use appropriate terminology. He knows his name, but does not know he is in the hospital. He has productive cough, which he spits in the emesis basin. The sputum is thick and yellow, with streaks of blood. Mr. L. states, “I smoke 3 packs of cigarettes a day for many years and I’m going to keep on smoking!” Laboratory values reflect an elevated level of carbon dioxide in his blood. On minimal exertion, he is experiencing shortness of breath (dyspnea); respiratory rate is 29 breaths/min and uses his abdominal accessory muscles to breathe. Capillary refill is sluggish, greater than 3 seconds. Both of his hands and feet are pale and cold to touch.
| Assessment | Diagnosis | Goal/expected outcome | Planning | Intervention | Rationale | Evaluation |
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Objective data:
Subjective data: |
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