Sample Nursing Care Plans

Nursing Diagnosis:  Ineffective breathing pattern related to right pulmonary agenesis as evidenced by high carbon dioxide levels and absent breath sounds on right side of the chest.

Assessment: 

• Vital signs: Monitor the patient’s heart rate, respiratory rate and SpO2 levels. Signs of respiratory distress include tachypnea, dyspnea and an SpO2 <95%.
• Breathing patterns: If the patient shows signs of respiratory distress, it should alarm the nurse, and interventions should take place. Signs of respiratory distress include nasal flaring, accessory muscles, grunting, shortness of breath, and retractions.
• CO2 lab values: When the body has an ineffective breathing pattern, inadequate gas exchange will take place. During this, the body retains CO2 and can enter into a stage of respiratory acidosis. Monitor for respiratory acidosis with blood gas lab values.
• Skin assessment: A person experiencing respiratory distress may experience pallor, cyanotic, and/or mottled skin.

SMART Goal: The patient will maintain a SpO2 level of >95%, RR of 30 to 55 breaths per minute, and heart rate of 80 to 140 beats per minute until the end of the shift.

Interventions: 

• Check manual heart rate and respiratory rate every four hours.
• Check patient is on continuous SpO2 monitor with pulse oximetry on the same extremity throughout shift.
• Obtain blood gases as ordered.
• Monitor for signs and symptoms of increased work of breathing and respiratory distress.

Evaluate:

• The patient is observed and/or documented to have SpO2, HR, and RR all within normal limits by end of the shift.
• The patient is documented to have received blood gas results that contain a CO2 value that is within the normal range.
• The patient is observed and documented to not experience any symptoms of respiratory distress throughout the shift.

Nursing Care Plan FAQs

• How do you write a nursing care plan?

  • Writing a nursing care plan takes time and practice. It is something you will learn during nursing school and will continue to use throughout your nursing career. First, you must complete an assessment of your patient to determine the nursing diagnosis and include relevant patient information. Next, utilize a NANDA-approved diagnosis and determine expected and projected outcomes for the patient. Finally, implement the interventions and determine if the outcome was met. 

• What is the purpose of the nursing care plan?

  • Nursing care plans provide a means of communication among nurses, their patients, and other healthcare providers to achieve healthcare outcomes.

• What are the 5 main components of a care plan?

  • There are five main components to a nursing care plan including; assessment, diagnosis, expected outcomes, interventions, and rationale/evaluation. 

• What is included in a nursing care plan?

  • Nursing care plans include relevant information about the patient’s assessment, goals of treatment, interventions that need to occur, and observations. These observations may include subjective and objective data.