NURSING CARE PLAN NO.

1




Date Identified: May 8, 2014

Assessment:
Subjective: Giubo man ko karon, naa rabay hukal
Objective:
Pale lips and oral mucosa
Crackles upon auscultation on both lower lung fields
Productive cough

Nursing Diagnosis: Ineffective airway clearance related to retained secretions in the base of the lungs

Planning: Within 1 hour of nursing interventions, the patient will be able to demonstrate behaviors to
clear and obtain airway patency.

Interventions:
1. Identify patient populations at risk.
- Patients under mechanical ventilation are more prone to accumulation of secretions and
those with poor swallowing reflexes.
2. Monitor respirations and breath sounds, noting rate and sounds.
- Indicators of respiratory distress and accumulation of secretions.
3. Keep environment allergen free: free of dust and smoke.
- Help reduce stimulation and maintains adequate and patent airway.
4. Encouraged to stay away from people who are smoking.
- Prevents inhalation of smoke that may lead to irritation of mucous membranes and further
aggravate cough.
5. Instruct the patient to elevate head of bed when sleeping or lying down.
- To open or maintain open airway in at-rest or compromised individual.
6. Demonstrate and encourage deep breathing and coughing exercises.
- Maximizes respiratory effort, enhances optimal lung expansion.
7. Advise to do proper splinting techniques when doing the above mentioned exercises.
- To see the chest rise and fall as well as to reduce tension on the post-operative areas in
cases that pain occurs.
8. Perform chest tapping if not contraindicated for the patients condition and as.
- Mobilizes secretions and aids in expectoration.
9. Provide and encourage periods of rest and limiting activities to level of respiratory tolerance.
- Reduces fatigue and conserves oxygen in the body.
10. Discuss the importance of spitting out phlegm rather than swallowing them.
- Reduces further lodging of microorganisms and gets rid of the secretions that impair airway
clearance.
11. Encourage to increase fluid intake to at least 2-3 liters a day.
- Liquefies and helps in mobilizing secretions in the lungs.

Evaluation: After 1 hour of nursing interventions, the patient was able to demonstrate ways of
maximizing respiratory effort and clearing airway as evidenced by participation during deep breathing
and coughing exercises, and modifying head of bed height by placing 2 pillows to elevate her upper body
when lying down.

Date Evaluated: May, 8 , 2014






























NURSING CARE PLAN NO. 2


Date Identified: May 9 , 2014

Assessment:
Subjective: Sakit akong tahi. Naa sa 7 ang kasakit.
Objective:
Grimace
Guarding movement
Irritable
Respiratory rate: 22 cpm

Nursing Diagnosis: Acute Pain related to post operative incision

Planning: Within 1 hour of nursing interventions, the patient will be able to demonstrate techniques to
reduce pain and verbalize relief and reduction of pain from 7 to 3 on a 10-point scale system.

Interventions:
1. Obtain and monitor vital signs, noting alterations.
- Serves as baseline data. Pain causes alterations in vital signs especially in respiratory and
pulse rates.
2. Assess the surgical site.
- To determine if signs of infection are present or any alterations such as dislodgement and
wrong positioning of the tube.
3. Position for comfort by allowing to turn to unaffected side and by placing a trochanter roll on
the affected area.
- Prevents pressure on the surgical site.
4. Instruct and demonstrate proper deep breathing and coughing exercises.
- Reduces tension and promotes optimal lung expansion.
5. Encourage adequate rest periods.
- Prevents fatigue and allows relaxation.
6. Encourage diversional activities.
- Alleviates patients perception of pain.
7. Review procedures/expectations and tell the client to a maximal dosage.
- To reduce concern of the unknown & associated muscle tension.
Dependent:
1. Administer Tramal 50mg IVTT as needed.
- Binds to certain opioid receptors and inhibits reuptake of nor-epinephrine and serotonin

Evaluation: After 1 hour of nursing interventions, the patient was able to demonstrate deep breathing
exercises and proper repositioning to minimize pain sensation and verbalize a reduction in
pain felt as evidenced by Ma tolerate naman ang sakit basta di lang ko mulihok arun dili
matandog.

Date Evaluated: May 9, 2014





































NURSING CARE PLAN NO. 3


Date Identified: May 10 , 2014

Assessment:
Subjective: Dili ko gusto mulihok kay magsakit na jud.
Objective:
Slowed Movement
On the bed all the time
Guarding movement on the surgical site
Difficulty turning
Nursing Diagnosis: Impaired physical mobility (Level 1) related to discomfort.
Planning: Within 8 hours of nursing interventions, the patient will be able to demonstrate techniques
that enable resumption of activities and increase level of strength and function.
Interventions:
1. Assess for impediments to mobility (pain or fear of discomfort).
- Identifying the specific cause (pain or fear of discomfort). Guides design of optimal
treatment plan
2. Observe movement when patient is unaware of observation.
- To note for any incongruencies with reports of abilities.
3. Place pillows on the sides of the bed.
- This promotes a safe environment.
4. Allow patient to perform tasks at his or her own rate. Do not rush patient. Encourage
independent activity as able and safe.
- Hospital workers and family caregivers are often in a hurry and do more for patients than
needed, thereby slowing the patients recovery and reducing his or her self-esteem.
5. Turn and position every 2 hours or as needed.
- Optimizes circulation to all tissues and relieves pressure.
6. Perform passive and active range of motion activities such as flexing and extending extremities.
- Exercise promotes increased venous return, prevents stiffness, and maintains muscle
strength and endurance.
7. Provide positive reinforcement during activity.
- Patients may be reluctant to move or initiate new activity due to a fear of falling.
8. Encourage and demonstrate deep breathing exercises.
- Promotes optimal lung expansion and supplies oxygen demands.
9. Instruct to eat high calorie foods such as lean meat and nuts.
- Calorie can supply energy for individual bodily needs.
10. Encourage fluid intake within level of limitation.
- Liquids optimize hydration status.
Evaluation: After 8 hours of nursing interventions, the patient was able to do active range of motion
exercises and ambulate with minimal assistance from the significant other. She was able to verbalize,
Mag-exercise nalang ko pirmi kada buntag maski ginagmay lang.
Date Evaluated: May 10, 2014
























NURSING CARE PLAN NO. 4


Date Identified: May 10 , 2014

Assessment:
Objective:
Reddish discharge at incision site
Foul odor at dressing
Dressing is dry and intact
Nursing Diagnosis: Risk for infection related skin trauma at incision site
Planning: Within 4 hours of nursing interventions, the patient will be able to demonstrate techniques to
reduce possible occurrence of infection and be free from signs of infection.
Interventions:
1. Monitor vital signs especially temperature.
- Reflective of inflammatory process/infection, requiring evaluation and treatment.
2. Observe for signs of infection such as swelling, redness, pain and fever.
- To evaluate if an infection is occurring.
3. Assess the condition of the surgical incision.
- Moist environment increases the incidence for bacterial multiplication.
4. Instruct to do proper handwashing to the patient and to the significant others as well.
- A first-line defense against infections. Limit exposures, thus reducing cross-contamination.
5. Advise not to frequently touch the insertion site.
- This may lead to cross-contamination of microorganisms.
6. Encourage to take a bath or at least cleanse the body regularly.
- Personal hygiene is very important in maintaining infection prevention.
7. Promote adequate fluid intake within limits.
- Metabolism during infection is increased. Fluid supports hydration in the body at this time.
8. Encourage to eat food rich in protein in small amounts as indicated for diet.
- For faster healing of the wound.
9. Advise to increase food intake on Vitamin C rich foods such as citrus fruits.
- Boosts immune system to fight possible occurrence of infection.
10. Discuss to the patient the importance of keeping the dressing dry at all times.
- This facilitates cooperation of the patient in determining tendencies of possible occurrence
of infection from having a moist dressing.
Evaluation: After 4 hours of nursing interventions, the patient was able to demonstrate techniques to
reduce possible occurrence of infection such as by washing hands and doing body cleansing. She was
also able to verbalize, Dili nako pirmi hikapon akong dressing kay para dili mahugaw.
Date Evaluated: May 10, 2014


NURSING CARE PLAN NO. 5

Date Identified: May 10, 2014
Assessment:
Subjective: Magkaon-kaon nako pirmi. Bahala ug ginagmay basta kanunay.
Wala naman koy limit sa tubig mao muinom nakog daghan karun.
Objective:
Prepares own meals
Arranges dietary supplements on medication kit
Nursing Diagnosis: Readiness for enhanced nutrition
Planning: Within 2 hours of nurse-patient interaction, the patient will be able to demonstrate
techniques to maintain appropriate weight and be able to prepare foods that are appropriate for her
condition.
Interventions:
1. Assess and monitor patients weight regularly and record; having the patient weighed on the
same time of the day and in the same type of clothes.
- Monitor changes in patients weight with accuracy.
2. Auscultate bowel sounds, note characteristic and amount of stools.
- To evaluate degree of deficit.
3. Determine eating habits, including food preferences and intolerances.
- To appeal to patients likes and dislikes.
4. Encourage small, frequent feedings.
- To supply body requirements for nutrients and avoid untimely satiety.
5. Instruct on uremic diet; that is to eat foods low in uric acid by limiting intake of beans, sardines
and organ meats.
- Uric acid is a metabolic waste product and cannot be metabolized well by the affected liver.
6. Allow the patient to choose her own food that would be appealing to her.
- This would stimulate the patients appetite.
7. Promote pleasant and relaxing environment, limiting unpleasant odors and sights.
- Measures to increase appetite and mood for intake.
8. Instruct and provide proper oral care before and after meals.
- The mouth is the first step in the digestive cycle and is responsible for food intake;
alterations in the oral cavity can decrease appetite and hinder intake.
9. Emphasize importance of well-balanced, nutritious intake such as eating foods high in vitamins
and minerals such as green leafy vegetables and citrus fruits.
- Provides body building nutrients for individual needs.
Evaluation: After 2 hours of nurse-patient interaction, the patient was able to create a list of foods that
she is planning to eat according to her prescribed diet that consisted of fruits and vegetables. She was
also able to continue taking her food supplements that were prepared ahead of time in a medication kit.
Date Evaluated: May 10, 2014