I need 3 nursing care plans diagnosis are 1. each care plan need to have the diagnosis, related to, As Evidence by, subjective and objective , short-term and long term goal, intervention, rationales, evaluation Purchase the answer to view it Purchase the answer to view it Purchase the answer to view it Purchase the answer to view it Purchase the answer to view it Purchase the answer to view it

Title: Nursing Care Plans for Three Common Diagnoses in Adult Patients

Introduction:
Nursing care plans are essential tools used by nurses to provide comprehensive and individualized care for patients. These plans are guided by the nursing diagnosis, which helps prioritize the patient’s needs and formulate goals and interventions to address them. In this assignment, we will develop three nursing care plans for adult patients, each addressing a common nursing diagnosis. The three nursing diagnoses chosen for this assignment are:

1. Impaired Gas Exchange related to pneumonia, as evidenced by decreased oxygen saturation levels and abnormal lung sounds.
2. Impaired Skin Integrity related to immobility, as evidenced by pressure ulcers on the coccyx area.
3. Risk for Falls related to gait disturbance, as evidenced by unsteady gait and recent history of falls.

Nursing Care Plan 1: Impaired Gas Exchange related to pneumonia
1. Nursing Diagnosis: Impaired Gas Exchange related to pneumonia
2. Related to: Inflammatory process in the lungs, as evidenced by decreased oxygen saturation levels and abnormal lung sounds.
3. As evidenced by: Decreased oxygen saturation levels (SpO2 < 92%), abnormal lung sounds (e.g., crackles, wheezing). Short-term Goal: The patient will maintain oxygen saturation levels above 92% within 48 hours. Long-term Goal: The patient will demonstrate improved respiratory function as evidenced by clear lung sounds and oxygen saturation levels within the normal range. Interventions: 1. Administer supplemental oxygen as prescribed. Rationale: Supplemental oxygen helps improve oxygenation and alleviate hypoxia, ensuring adequate oxygen supply to the body. 2. Encourage deep breathing and coughing exercises every 2 hours. Rationale: Deep breathing and coughing help mobilize secretions, promote lung expansion, and improve oxygenation. 3. Assist with proper positioning, such as elevating the head of the bed. Rationale: Proper positioning helps optimize lung ventilation and prevent the collapse of alveoli. 4. Administer prescribed medications, such as bronchodilators and antibiotics. Rationale: Bronchodilators help open airways, improving gas exchange, while antibiotics treat the underlying infection. Evaluation: After 48 hours of implementing the nursing interventions, the patient's oxygen saturation levels improved and remained above 92%. Lung sounds became clearer, indicating improved gas exchange. Nursing Care Plan 2: Impaired Skin Integrity related to immobility 1. Nursing Diagnosis: Impaired Skin Integrity related to immobility 2. Related to: Prolonged pressure on the coccyx area, as evidenced by pressure ulcers. 3. As evidenced by: Presence of pressure ulcers on the coccyx area. Short-term Goal: The patient's pressure ulcers will show signs of healing within 1 week. Long-term Goal: The patient will maintain intact skin integrity, without the development of new pressure ulcers, throughout the hospital stay. Interventions: 1. Assess the pressure ulcers for size, depth, and signs of infection. Rationale: A thorough assessment helps determine the severity of the ulcers and guides appropriate treatment interventions. 2. Implement a pressure ulcer prevention program, including regular repositioning and skin assessment. Rationale: Repositioning helps relieve pressure and redistributes weight, preventing further tissue damage. 3. Clean the pressure ulcers with sterile saline solution and apply appropriate dressings as per healthcare provider's orders. Rationale: Cleanliness and proper dressing promote wound healing and prevent further infection. 4. Educate the patient and family/caregivers about the importance of regular turning and proper skin care. Rationale: Patient and family involvement in prevention measures promotes compliance and reduces the risk of developing new ulcers. Evaluation: After 1 week, the pressure ulcers showed signs of healing, with decreased size and no signs of infection. The patient and the patient's family demonstrated correct turning techniques and understood the importance of ongoing skin care. Nursing Care Plan 3: Risk for Falls related to gait disturbance 1. Nursing Diagnosis: Risk for Falls related to gait disturbance 2. Related to: Gait disturbance and unsteady gait, as evidenced by recent falls. 3. As evidenced by: Unsteady gait, recent history of falls. Short-term Goal: The patient will remain free from falls during their hospital stay. Long-term Goal: The patient will demonstrate improved balance and coordination, as evidenced by preventing falls after discharge. Interventions: 1. Assess the patient's gait and balance through coordination tests. Rationale: Evaluation of gait and balance helps determine the extent of impairment and guides appropriate interventions. 2. Implement a fall prevention program, which includes using assistive devices (e.g., walking aids), providing a safe environment, and removing any obstacles. Rationale: The use of assistive devices and maintaining a safe environment reduces the risk of falls and promotes patient safety. 3. Provide patient and family education on fall prevention strategies, including the use of handrails, sit-to-stand techniques, and taking precautions when ambulating. Rationale: Educating the patient and family members enhances awareness and underscores the importance of active participation in fall prevention. 4. Collaborate with physical therapy for gait training, muscle strengthening exercises, and balance exercises. Rationale: Physical therapy interventions improve gait and balance, reducing the risk of falls. Evaluation: Throughout the hospital stay, the patient remained free from falls. The patient's gait and balance showed improvement, and they demonstrated correct use of walking aids and proper precautions when ambulating. Physical therapy interventions contributed to the patient's enhanced mobility and reduced risk of falls.