Page 82 - Modul English Communication In Nursing

Communicating Nursing Care plan

Planning nursing care that demonstrate expressing priority, stating goals and
criteria, and elaborating on the appropriate type of intervention.

Based on the nursing care plan provided, carefully analyze the patient’s condition and write three
sentences for each of the following: expressing priority, stating goals and criteria, and detailing nurse
interventions. Ensure your sentences are clear, concise, and relevant to the patient’s specific
symptoms and needs. This exercise will help you develop essential skills in creating effective and
patient-centered care plans. Number 1 has been done for you.

NURSING CARE PLAN 1
Patient Name : Mr. Lee
Age : 72
Diagnosis : Congestive Heart Failure
Symptoms : Shortness of breath, fluid retention, fatigue, SpO₂ at 88%, elevated
blood pressure at 150/95 mmHg, weight gain of 5 pounds in the last
two days due to fluid buildup.
Medical History : Hypertension, Diabetes
Priority
The immediate priority is to improve Mr. Lee’s oxygen saturation, as his SpO₂ level is below the
acceptable range, which could exacerbate his shortness of breath and further compromise his
cardiovascular health.

Goals and Criteria
Short-term Goal : Increase Mr. Lee’s SpO₂ to 92% or higher within the next hour to
ensure adequate oxygenation.

Long-term Goal: : Reduce fluid retention by decreasing swelling in his ankles and legs
over the next 24 hours through diuretic therapy and dietary
adjustments.

Criteria: : Measure success through consistent SpO₂ readings above 92%, a
weight reduction of 2 pounds within 24 hours, and a noticeable
reduction in swelling.

Nurse Interventions
Independent Interventions: : 1. Monitor Mr. Lee’s oxygen saturation every 15 minutes, adjusting
the oxygen flow rate as prescribed.
2. Elevate Mr. Lee’s legs to help reduce fluid retention and swelling.
3. Educate Mr. Lee on the importance of maintaining a low-sodium
diet to manage fluid retention.

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