POLYTECHNIC COLLEGE OF DAVAO DEL SUR, INC.

MacArthur Highway, Digos City

NURSING CARE PLAN
Name of Patient: Casas__________________________________
Age: 5 yrs old Sex: Male__Civil Status: Married_____________
Occupation: laborer Religion: Roman Catholic_____________
Address: _______________________________________________
Ward: Medicine Ward Room No.: #33 Non-infectious_Bed No.#4_
Attending Physician:Dr. Maria Lourdes G. Pasaporte-Alisasis______________
Diagnosis: Community Acquired Pneumonia - Moderate Risk______________
_______________________________________________________________
Chief Complaint: dyspnea, cough____________________________________
Date of Admission: January 5, 2018___________________________________

Date/Time Cues Needs Nursing Scientific Basis Goals Objectives Nursing Interventions Rationale Evaluation
Diagnosis Criteria

Jan. 11, Subj: H Risk for Within 8 hours of 1. Monitor vital signs. 1. Establishes baseline data for GOAL MET
2018 “Maglisod E aspiration nursing intervention, 2. Assess level of review of existing
@ gyapon sya og A SOURCE: Med- patient demonstrate consciousness. conditions.
8AM tulon daghan L Surg Lippincott no further 2. Within 8 hours of
kayo og plema T Williams deterioration/recurre nursing
sa iyang baba,” H &Wilkins page nce of deficits as intervention,
as verbalized - 5th edition manifested by: patient was able
to be free from
by patient’s P  VS within normal
SO. E any signs of
limits
injury as
R  Absence of signs
Obj: C manifested by:
of increased ICP
 Vital signs of:
E 
 With P T: 36.8 C
patent and T PR: 120 bpm
intact NGT I RR: 30 cpm
noted O  No signs of
 Productive N skin
cough / breakdown
noted with M  Maintained
yellowish A treatment
phlegm N regimen to
 A control or
G eliminate
E seizure
M activity such
E as adhering
N to
T medication
prescribed
 P  Recognized
A need for
T assistance to
T prevent
E accidents or
R injuries
N  Maintained
safe
environment
such as using
pillows on
patient for
support,
lowering
position of
bed

Name: Mary Shan Padilla_______________ Year & Sec:BSN 4________ Group No.:____________ Rating: __________
Reference: NANDA____________________________

Criteria: Promptness (5%) _________ Objectives of Care (10%) _________

Format/Neatness (15%) _________ Nursing Action (40%) _________
Assessment (15%) _________ Evaluation (10%) _________
Nursing Diagnosis (15%)_________
Clinical Instructor: Mr. Jay Pee C. Malibiran, RN
 POLYTECHNIC COLLEGE OF DAVAO DEL SUR, INC.
MacArthur Highway, Digos City
NURSING CARE PLAN
Name of Patient: Limosnero, Andres __________ Attending Physician: Dr. Natividad____________________________________
Age: 84 yrs old Sex:Male___Civil Status: Married________________ Diagnosis: Community Acquired Pneumonia- Moderate Risk_______________
Occupation: Senior Citizen Religion: Roman Catholic______________ _________Decubitus Ulcer__________________________________________
Address: Purok 1, Bala, Magsaysay, Davao del Sur________________ Chief Complaint: fever, chills_________________________________________
Ward: Medicine Ward Room No.: #33 Non-infectious Bed No.#5_____ Date of Admission: Oct. 9, 2017 @ 8:30 PM_____________________________
Date/Time Cues Needs Nursing Scientific Basis Goals Objectives Nursing Interventions Rationale Evaluation
Diagnosis Criteria
Nov. 22, Subj: A Ineffective A neonate’s lung Within 8 hours of 1. Monitor VS. 1. To obtain baseline GOAL MET
2017 “Magsige sya C breathing is structurally nursing 2. Assess mentation for signs data Within 8 hours of nursing
@ og kapunga”, T pattern underdeveloped intervention, the of hypoxia or hypercapnia. 2. Restlessness, intervention, the infant as
8AM as verbalized I related to for postnatal life. infant will establish 3. Assess capillary refill time. inappropriateness, able to establish an
by patient’s V immature To add, the an effective 4. Assess RR and pattern. frequent crying effective breathing
mother. I neurologic and delivery and the breathing pattern 5. Auscultate lung sounds and should be watched pattern as manifested by:
T delayed inadequate as manifested by: note presence of crackles or out for
Obj: Y pulmonary pulmonary wheezes 3. To determine  Infant’s RR of 53 cpm
- development surfactant. A  Infant’s RR is 6. Maintain on moderate high adequate  No episodes of apnea
 With O2 E secondary to deficiency in between 40 back rest position. oxygenation  Good capillary refill of
via nasal X neonatal sepsis surfactant, and 60 cpm 7. Maintain oxygenation as 4. To provide up to 3 secs
cannula E which functions  No episodes of ordered. information about  Normal skin color
regulated R to decrease the apnea 8. Provide tactile stimulation neonate’s ability to  Prevented
at 2 lpm C surface tension  Good capillary during periods of apnea initiate and sustain an complications such as
 With RR of I within the refill of up to 3 9. Promote restful and quiet effective breathing hypoxia
64 cpm S alveoli. Without secs environment pattern  SO verbalization of
 Labored E surfactant, the  Normal skin 10. Emphasized to mother 5. Reveals presence of “bantayan nko akong
breathing infant color about providing pulmonary anak na makahinga
noted P experiences  Prevent breastfeeding with strict congestion/ og tarung, permi nko
 Pale skin A diffuse complications aspiration precaution collection of bantayan ang
color T atelectasis, such as 11. Administer medications as secretion, indicating position nya matulog,
noted T decreased hypoxia ordered. need for further banatayan pud nko
 Episodes E pulmonary  SO verbalize intervention inig magpatotoy ko.”
of apnea R compliance, understanding 6. To allow lung
(3-6 secs) N ventilation of causative expansion
perfusion factors and 7. To provide adequate
mismatching, appropriate oxygenation
and significant interventions 8. stimulation of the
increase in the such as sympathetic nervous
work maintaining system increases
patient on respiration
moderate high
back rest
position