HNN227 :Care Plan Assessment

Actual or Potential?

Rationale

1.Impaired comfort

2.Risk of Fluid and electrolyte imbalance

3.Impaired gas exchange

4.Risk of altered tissue perfusion

Re-constructed Patient Problem

1.Actual Problem

related to

as evidenced by

2.Actual Problem

related to

as evidenced by

3.Potential Problem

due to

4.Potential Problem

due to

PatientProblem

1stPriority

2ndPriority

3rdPriority

4thPriority

Planning

1.Impaired comfort

2.Risk of fluid and electrolyte imbalance

3.Impaired gas exchange

4.Risk of altered tissue perfusion

Evidence-based NursingIntervention

1.Impaired comfort

1.

2.

2.Risk of fluid and electrolyte imbalance

1.

2.

3.Impaired gas exchange

1.

2.

4.Risk of altered tissue perfusion

1.

2.

Evidence-based Nursing Intervention

Rationale

1.Impaired comfort

1.

2.

Evidence-based Nursing Intervention

Rationale

2.Risk of fluid and electrolyte imbalance

1.

2.

Evidence-based Nursing Intervention

Rationale

3.Impaired gas exchange

1.

2.

Evidence-based Nursing Intervention

Rationale

4.Risk of altered tissue perfusion

1.

2.

Evaluation

1.Impaired comfort

2.Risk of fluid and electrolyte imbalance

3.Impaired gas exchange

4.Risk for altered tissue perfusion