b) Nursing Care Plans

Problem#1: Acute Pain

Cues
S> Masakit ku salu,
as verbalized by the
pt.
O> The patient may
manifest:
- tachycardia
- tachypnea
- sleep disturbance
- facial grimaces
- irritability
>The
patient
manifested:
- with oxygen hooked
via nasal cannula
regulated at 2 lpm
with
condomcatheter
attached to urine bag
- continuous cardiac
monitoring

Nursing
Diagnosis

Scientific
Explanation

Acute
Pain
related
to
increased lactic
acid production
secondary
to
decreased blood
and
oxygen
supply
to
myocardium

Acute Pain is the

prioritized problem
because it suggests
ischemia which is
very fatal. In acute
myocardial
infarction
more
commonly known
as heart attack, a
medical condition
that occurs when
the blood supply to
a part of the heart is
interrupted,
most
commonly due to
rupture
of
a
vulnerable plaque.
The
resulting
ischemia or oxygen
shortage
causes
damage
and
potential death of
heart
tissue.
Because
of
decreased
blood
and oxygen supply
to
myocardium,
shifting
from
aerobic
to
anaerobic
metabolism
happens thus there
is an increase in
lactic
acid
production causing
irritation to the heart
muscle.
This
mechanism causes
a feeling of pain
which may activate
the
sympathetic
nervous
system
thus
causing
tachypnea
and
tachycardia as a
response. Due to
the uncomfortable
sensation,
the
patient may be

Objectives
Short term:
After 4 hours of
NI, the patient
will report relief of
pain.

Nursing Interventions
>Establish rapport

>to g
cooper

>Assess
condition

>to det

patients

>Monitor VS

Long term:
After 2 days of
NI, the patient
will demonstrate
use of relaxation
techniques and
divertional
activities
as
indicated
for
individual
situation.

>to o
data

>Perform
comprehensive
assessment of pain

>Assess respirations,
BP and heart rate with
each episodes of chest
pain.

>to
precipit

> respi
increas
of pain
anxiety

>Observe
cues

nonverbal

>Provide
measures
back rub

comfort
such as

>to
pharma
measur
pain

>Provide adequate rest

periods

>to pre
promot

>obser
may/ma
congru
reports
for furth

>Maintain bed rest

during
pain,
with
position of comfort,
maintain
relaxing
environment
to
promote calmness.
>Prepare
for
the
administration
of
medications,
and
monitor response to
drug therapy. Notify
physician if pain does

>to r
consum
deman
compet
reduce

>pain
priority,
ischem

seen with
grimaces
irritability.

facial
and

not abate.

>to pro
>Review
ways
lessen pain

to

>promo
passive
>Provide
for
individualized physical
therapy/exercise
programs that can be
continued by the client
when discharged
>Discuss with SO(s)
ways in which they can
assist
client
and
reduce
precipitating
factors that may cause
or increase pain
>Instruct patient/family
in medication effects,
side-effects,
contraindications and
symptoms to report

>to pro

>
knowle
complia
therape
and to
unknow

Problem#2: Ineffective airway clearance

Cues

Nursing Diagnosis

S> The patient

may verbalize:
- dyspnea

Ineffective
airway
clearance r/t retained
tracheobronchial
secretions
AEB
presence
of
productive cough

O> The patient

manifested:
productive
cough
- fuzziness of
the
lung
markings
in
both lungs
- with oxygen
hooked
via
nasal cannula
regulated at 2
lpm
- with condom
catheter
attached
to
urine bag
continuous

Scientific
Explanation
Pneumonia is an
infectious disease
characterized by
inflammatory
processes
affecting the lung
parenchyma. The
invading organism
causes symptoms,
in
part,
by
provoking
an
overly exuberant
immune response
in the lungs.
Mucus production
is increased which
plugs the airway
thus
further
compromising the
airway clearance
of the patient. This
event may bring

Objectives
Short term:
After 4 hours of NI, the
patient will demonstrate
behaviors to improve or
maintain airway patency.

Long term:
After 4 days of NI, the
patient will demonstrate
absence/reduction
of
congestion with breath
sounds
clear,
respirations
noiseless
and improved oxygen
exchange.

Nursing
Interventions

>Establish rapport

>to g
cooper

>Assess patients
condition

>to de

>Monitor VS

>to o
data

>Auscultate breath
sounds

> to n
adven
sound

>Assess
respiratory
movements
and
use of accessory
muscles

> us
muscl
indica
abnor
work o

>Observe for signs

> to id
proce
timely

cardiac
monitoring
> The patient
may manifest:
- changes in
respiratory rate
or rhythm
- diminished or
adventitious
breath sounds
- cyanosis

about cyanosis. In
order
to
compensate, the
patient
may
breathe rapidly in
order to bring in
more oxygen thus
manifesting
changes
in
respiratory rate or
rhythm.

and symptoms of
infection

>to
severi

>Monitor
chest
radiograph reports

>to
expan

>Use positioning
by placing on a
semi-high fowlers
position

> to ta
gravity
pressu
diaphr
enhan
ventila
lung s

>Elevate head of
bed or change
position every 2
hours and prn

>to
mobili
secret

>to lo

>Maintain
adequate
hydration
possible

> to c
secret
blocki
when

>
Perform
nebulization
and
CPT as indicated
>Institute
suctioning
needed

as

>Use
nasopharyngeal / oropharyngeal airway
as needed
>Administer
medication
prescribed

as

>Administer
analgesics
prescribed

as

>Refer
appropriate

to

> to
airway
artifici

>to
pharm
mana
condit

>to m
when
effort

> to pr
of care

support groups

Problem#3: Impaired Gas Exchange

Cues
S> The patient
may verbalize:
- dyspnea
O> The patient
manifested:
productive
cough
- fuzziness of the
lung markings in
both lungs
- with
oxygen
hooked via nasal
cannula
regulated at 2
lpm
with condom
catheter attached
to urine bag
continuous
cardiac
monitoring
> The patient
may manifest:
- confusion
- lethargy
- abnormal ABGs
- cyanosis

Nursing
Diagnosis

Scientific
Explanation

Impaired
Gas
Exchange
r/t
collection
of
secretions
affecting oxygen
exchange
across alveolar
membrane

Pneumonia
both
affects ventilation
and diffusion. An
inflammatory
reaction can occur
in
the
alveoli,
producing exudates
that interfere in the
diffusion of oxygen
and carbon dioxide.
White blood cells,
mostly neutrophils,
also migrate into
the alveoli and fill
the normally aircontaining spaces.
Areas of the lungs
are not adequately
ventilated because
of secretions and
mucosal edemathat
cause
partial
occlusion of the
bronchi or alveoli,
with a resultant
decrease
in
alveolar
oxygen
tension.
An
imbalance
in
oxygen and carbon
dioxide exchange
may be evident in
the patients arterial
blood gases. A
decrease in oxygen
supply may cause
confusion
and
lethargy.

Objectives
Short term:
After 4 hours of NI,
the patient will
demonstrate
behaviors
to
improve
or
maintain
airway
patency.

Nursing
Interventions
>Establish rapport

>to
gain
cooperation

>Assess
condition

>to determine

patients

>Monitor VS
>Auscultate
sounds

Long term:
After 4 days of NI,
the patient will
demonstrate
absence
or
reduction
of
congestion
with
breath
sounds
clear, respirations
noiseless
and
improved oxygen
exchange.

Ratio

>to obtain bas

breath

>Assess respiratory
movements and use
of
accessory
muscles

>Observe for signs

and symptoms of
infection

>to note
adventitious

>use of acce
to breathe
abnormal inc
of breathing

>to
identif
process
a
timely interve
>to monitor
the disease

>to assess
insufficiency
>Monitor
chest
radiograph reports

>to
faci
expansion
>Evaluate
oximeter
determine
oxygenation

pulse
to

>Use positioning by
placing on a semihigh fowlers position
>Elevate head of bed
or change position
every 2 hours and
prn

> to take
gravity
pressure on
and enhanci
ventilation to
segments

>to aid in th
of secretions

>to loosen se

> to clear
secretions ar

airway
>Maintain adequate
hydration
when
possible
with
precautions on fluid
overload

> to have
through artifi

> helps
needs/consum

>Perform
nebulization
and
CPT as indicated
>Institute suctioning
as needed

>to
pharmacolog
managemen
condition

>Use
nasopharyngeal / oropharyngeal airway as
needed
>Encourage
adequate rest and
limit
activities
to
within
client
tolerance

>to maximize
pain is inhibiti

>Administer
medication
prescribed

as

>Administer
analgesics
prescribed

as

>Refer to appropriate
support groups

> to promote
care