NURSING CARE PLAN

\ PATIENTS NAME: AGE: 7 years old DIAGNOSIS: Congenital Heart Disease Double Outlet Right ventricle with Pulmonary Stenosis ASSESSMENT OBJECTIVE: Cyanotic lips Pale conjunctiva and nail beds Weak peripheral pulses Cold clammy skin Dry, scaly skin Decreased skin turgor >4 seconds Decrease capillary refill 4 seconds NURSING DIAGNOSIS Ineffective tissue perfusion r/t decreased cardiac output INFERENCE Due to decreased cardiac output, there is decreased preload and stroke volume thus there is decreased blood pumped out from the blood. Decrease in stroke volume decreases perfusion throughout the body. GOAL SHORT-TERM: After 8 hours of nursing interventions, patient(guided by the mother) will be able to demonstrate behaviors to improve circulation, as evidence by: Engage foot-ankle exercises Use of pressure relieving devices(foam padding) Changes position at timed intervals INTERVENTION INDEPENDENT: Note current situation or presence of conditions that can affect perfusion to all body systems(CHD DORV with PS) Identify presence of high risk factors(problem in coronary circulation) Measure capillary refill Inspect lower extremities for skin texture(lack of hair, dry and scaly) Affecting systemic circulation/perfusio n To identify client at higher risk for venous stasis, vessel wall injury and hypercoagulability.. To determine adequacy of systemic circulation That often accompany diminished peripheral circulation SHORT-TERM: GOAL FULLY MET After 8 hours of nursing interventions, patient was able to demonstrate behaviors to improve circulation, as evidence by: Engage foot-ankle exercises Use of pressure relieving devices(foam padding) Changes position at timed intervals RATIONALE EVALUATION

LONG-TERM: After 2 days of nursing interventions, patient will be able to demonstrate

DEPENDENT Administer KCL and To promote optimal

LONG-TERM: PARTIALLY MET After 2 days of nursing interventions, patient was

ABG(respira tory alkalosis)

CBC(Decre ase hemoglobin and hematocrit)

increased perfusion, as evidence by: Warm skin Moist, smooth skin Peripheral pulses present and strong Normal skin turgor + 2 seconds Normal capillary refill <2 seconds Normal ABG result CBC(Hemoglobin and hematocrit within normal limits)

Ferrous Sulfate COLLABORATIVE: Collaborate in treatment of underlying conditions(cardiopulmo nary conditions) Refer to dietician

blood flow, organ prefusion, and function To maximize systemic circulation and organ perfusion For well-balanced, low saturated-fat, low cholesterol diet and other modifications as indicated.

able to demonstrate increased perfusion, as evidence by: Warm skin Peripheral pulses present and strong Normal skin turgor Normal capillary refill <2 seconds(not met) Normal ABG result(not met) CBC(Hemoglobin and hematocrit within normal limits)

NURSING CARE PLAN PATIENTS NAME: colds ASSESSMENT SUBJECTIVE Hirap siyang makahinga as verbalized by the mother OBJECTIVE Pale in appearance Presence of clear nasal discharge Presence of crackles on the bilateral lung field Ineffective NURSING DIAGNOSIS Ineffective airway clearance related to retained secretions AGE: INFERENCE Irritant (inhalation) GOAL LONG TERM After 3 days of nursing intervention, the client will have effective airway clearance as manifested by: EXPECTED OUTCOME clear breath sounds clear secretions good airway patency SHORT TERM INTERVENTION INDEPENDENT Monitor respiratory rate RATIONALE It is an indication of respiratory distress and accumulation of secretions To open or maintain airway and it also enhances drainage to different lung segments Physical or DIAGNOSIS: cough and EVALUATION LONG TERM After 3 days of nursing interventions, the goal has been fully met as manifested by: Absence of crackles Absence of secretions Having an effective airway clearance. Good airway patency SHORT TERM

inflammatory response

Position in a semi-fowlers position

increase production of secretions

Keep

coughing RR= 32 restlessness

Accumulation of secretions

Blocks the airway (airway constriction)

After 3 hours of nursing intervention, the patient will be able to expectorate secretions as evidenced by:

environment allergen free such as cleaning to remove dusts. Increase fluid intake

chemical allergen serves as irritants

After 3 hours of nursing intervention, the short term goal was fully met as evidenced by: Effective coughing clearing the retained secretions Enhanced airway patency Normal respiratory rate

changes in the respiratory pattern EXPECTED OUTCOME: Effective coughing and clearing of retained secretions Enhanced airway patency REFERENCE/S Medical Surgical Nursing, 11th Edition by Smeltzer and Bare, page 602 Normal respiratory

Hydration can help liquefy viscous secretion and improve secretion clearance It may compromise airway

dyspnea work of breathing increases to compensate for the blockage.

Monitor for feeding intolerance, abdominal distention and emotional stressors. Auscultate breath sounds and assess air movement Give chest physiotherapy

To ascertain status and note progress To remove bronchial secretions and improve ventilation To promote proper lung expansion Act as a bronchodilator

Encourage deep breathing exercises DEPENDENT Administer salbutamol neb as ordered

REFERENCE/S Medical Surgical Nursing, 11th Edition by Smeltzer and Bare, page 731.