Sample Care Plan Template Page 46

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4) Provide meticulous oral care including
4) There is a multitude of research data that
4) The nurse performed oral care on
brushing of teeth q2hrs. Good oral care can
shows that good oral care can reduce risk of
the patient q2hrs during the nursing
prevent contamination of the mouth, which can
aspiration pneumonia (Arpin, 2009).
shift.
be aspirated (Ackley & Ladwig, 2011, p. 872).
5) The patient’s BS were
5) Listen to bowel sound q6hrs to determine if
5) Decreased of absent BS indicate possible
they are decreased, absent, or hyperactive
ileus with possible vomiting and aspiration.
auscultated q6hrs and were normal.
(Ackley & Ladwig, 2011).
High-pitched bowel sounds indicate
mechanical obstruction with possible
vomiting and aspiration (Ackley & Ladwig,
2011).
Evaluation of outcome(s):
1. The outcome was met the patients lung sounds remained clear upon auscultation q4hrs during the nursing shift.
2. The outcome was met the patient had less than 200ml of gastric contents aspirated q8hrs from NG tube.
3. The outcome was met the nurse performed oral care q2hrs with toothbrush and chlorohexidine mouthwash, as well as performing
suctioning PRN when patient had secretions built up.
F:\group\MEPN\MEPN Level III\NURS610B\2013NURS 610B\610BCarePlan
12/17/2012
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