Plan of Care - Differences | Document

PLAN OF CARE
PATIENT or NURSING ORIENTED
PROBLEM OR PATIENT NEED
PATIENT ASSESSMENT DATA OPTIMAL PATIENT OUTCOME or
GOAL
Patient problem/issues/need - which is
related to <insert>
Patient problems/issues/needs can be
actual present and occurring now
Or potential when the patient is
considered to be
‘at risk of’.
As evidenced by (or how do we know this
problem exists)
Objective patient data
Subjective patient data
Lab and other test results
What do we (patient and nurse) want to
achieve:
Specific, measurable, attainable, realistic and
time orientated (SMART goals)
1.The patient is at a risk of low levels of
oxygen. (hypoxemia)
Her oxygen levels are 93% Use HOT to give the patient supplemental
Oxygen until it reaches 95%
2.
The patient is at a risk of dehydration
Reduced output of urine , which is 150mls for
more than 8 hours Encourage taking of clear fluids to replenish
fluid levels which shall lead to 800mls of urine
output in 24 hours.
3.The patient is at a risk of increased
temperatures
38.2’C is the patient’s temperature readings,
which is a bit high.
Administer paracetamols or use traditional
methods to regulate temperatures down to 37
degrees Celsius.
4.The patient is at a risk of high lactose Her readings registered 3mmol/L levels of
lactase
Give calcium supplements until the patient
attains 0.5 to 1 mmol/L of lactase

levels
5.
The patient is at a risk of increased
respiratory rate
She recorded 25 breaths per minute Give beta blockers medication for the patient to
attain 22 breaths per minute.
6. The patient is experiencing inadequate
tissue perfusion
The patient has got cool peripheries The patient to increase water intake to increase
blood flow and lead to normal peripheral
perfusion.
One row per problem
Up to 6 prioritised problems (minimum 4)
Alice plan of care
Alice is a patient with an age of 75. She has been admitted in the surgical ward for the last 3 days, with the risk of fall. She has been
under hypertension and diabetes medications which usage was stopped after admission. She has been administered sodium chloride which is
used to maintain her fluid balance. The medical professional has done assessment to her and various lab tests have been undertaken. Various
variations have been obtained from the tests about her blood pressure, circulation, heart beat rate, glucose levels, etc. This means that she has
gone through A to G assessment. She has a forced work of breathing and low oxygen levels.

In this paper, I will address two medical conditions basing them on the assessment, lab results and the criteria presented in the patient’s plan of
care. These conditions will enable me to look at what a nurse/medical practitioner can do to ensure they are cured for the safety of the patient.
This shall be done in line to the patient’s rights ensuring quality care, professionalism and at the same time acting as the patient’s advocate.
One of the medical problems include low oxygen levels, also called hypoxemia. Its assessment data as provided in care plan is 93%
registering low oxygen levels. The pathophysiology of this condition is that it exists when there is reduction of oxygen pressure in the blood
below the normal range. Tissue hypoxia exists when the amount of oxygen is reduced in the body tissues (Koelwyn, Jones, & Moslehi 2014). In
patients with COPD, the predominat hypoxia is the mismatching of V/Q.in the presence or the absence of alveolar hypoventilation, (Adak,
Maity, Ghosh, & Mondal 2014). The hypoxemia that is simple to correct is the one caused by V/Q mismatching because only a little amounts of
supplemental oxygen are needed for LTOT (Negro & Hodder 2013). Hypoxemia is a problem that leads to more ventilation and leads to dyspnea
and other signs and symptoms, (Chao, Wood, & Gonzalez 2011). In patients with COPD, chronic alveolar hypoxia leads to the development of
pulmonale – right ventricular hypertrophy in the absence or presence of overt right ventricular failure, (Anderson et al 2019).
There are four types of hypoxia, referred to as hypoxic hypoxia, stagnant hypoxia, histotoxic hypoxia and hypemic hypoxia (McDonnell &
Chandraharan 2014). They all have the same impacts to a patient. Hypoxemia may be caused by heart conditions such as the heart defects and
lung conditions such as bronchitis and asthma, (Javed & Moore 2018). In the case provided above, the oxygen levels have reduced to 93%
instead of 95%. Another symptom from the medical assessment that shows that there is inadequate oxygen in the patient’s circulatory system is
the poor tissue perfusion due to cool peripheries. This means that the oxygen in the blood is not enough to reach all the body parts hence the

inadequate tissue perfusion. Alice suffers high work of breathing because the heart is straining to supply the blood to the body parts. The signs
and symptoms of hypoxemia include changes in the colour of the skin where the patient may look pale or reddish, confusion just as Alice is, a
fast heart rate, a high rate of breathing, sweating and also wheezing. All these symptoms may not appear at the same time. Poor tissue perfusion
due to cool peripheries is also a symptom in Alice during assessment, an indication of less oxygen in the circulatory system that can reach all the
body parts, (Ait-Oufella & Bakker 2016).
Medical interventions for this condition include giving supplemental oxygen by the use of HOT, ("Supplemental Oxygen Devices with
Automatic or Manual Presentation,"). This provides the body with the extra needed oxygen to support all the body vital functions. An oxygen
concentrator is used to give the patient oxygen that is higher than the oxygen available in the air.
Another intervention is raising the head of the patient off the bed that facilitates effective breathing and descent of the diaphragm. This makes it
possible to maximize inhalation and decrease the increased breathing work in the patient. The patient is as well able to gain relief due to the
raised position. poor tissue perfusion due to cool peripheries
Intervention involves practicing deep breathing and coughing techniques which enables the patient to clearly open the airway and maintain their
levels of oxygen. The nurse taches the patient controlled coughing by taking a deep breath in and deeply cough with a slightly open mouth. The
patient takes a medium breath and makes sound to push air out. the exercise is done for three to four times until they get instructions to cough.
Dehydration may be done in this case if the patient has thick and tenacious secretions that shows the need of extra fluids. Another intervention