Nursing Care Plan # 1:

ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING NURSING RATIONALE EVALUATION

BASIS INTERVENTIONS

S: “Hirap akong Ineffective Damage to Objective: Independent: Independent: Objective:

huminga kahit na airway epithelial cells of At the end of 1. Assess airway for 1. Maintaining patent At the end of 15

nagsasalita lang ako, clearance the bronchi 15 minutes of patency airway is always minutes of

para ba akong related to nursing 2. Auscultate lungs the first priority, nursing

nahahapo,” as excessive interventions, for presence of especially in cases interventions, the

Pathogens enters
verbalized by the mucus the patient will normal or like trauma, acute patient will be
the body
patient. secretions be able to adventitious breath neurological able to identify

O: secondary to identify and sounds decompensation, and avoid specific

-Accessory muscles inflammation, avoid specific 3. Teach the patient or cardiac arrest factors that inhibit
Inflammatory
upon respiration as manifested by factors that the proper ways of 2. Abnormal breath effective airway
response
-Presence of wheezing inhibit coughing and sounds can be clearance.

supplementary sounds upon effective breathing heard as fluid and

oxygen via nasal auscultation. Increased mucus airway 4. Position the patient mucus accumulate. Goal:

canula production clearance. upright if tolerated. This may indicate

-Awake Goal: Regularly check airway is At the end of 2

-IV access on right At the end of 2 the patient’s obstructed. days of nursing
Obstructed airway
arm with 1L D5 NM days of nursing position to prevent 3. The most interventions, the

interventions, sliding down in convenient way to patient will be

-Vital signs: Difficulty of the patient will bed. remove most able to maintain

BP: 130/80; breathing be able to 5. Perform suctioning secretions is clear, open

Temp: 36.0 C maintain clear, to the patient if coughing. So it is airways as

↓
PR: 120 bpm open airways necessary necessary to assist evidenced by

RR: 22 bpm Wheezing sounds as evidenced Dependent: the patient during clear breath
upon auscultation by clear breath 1. Administer this activity. Deep sounds.

sounds. mucolytics such as breathing, on the

N-Acetylcysteine, other hand,

as ordered by the promotes

physician oxygenation

Collaborative: before controlled

coughing.
1. Collaborate with 4. This position

the physician for promotes better

further assessment lung expansion

and interventions and improved air

needed to the exchange.

patient 5. Helps clear

secretions and

improves

respiration.

Dependent:

1. Helps patient

eliminate

excessive

secretions.

Collaborative:
1. Collaboration such

as assistance in

other procedures

helps for both

diagnosis and

treatment.
 Nursing Care Plan # 2:

ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

BASIS

S: "Madali akong Decreased Objective: Independent: Independent: Objective:

mapagod kahit na Cardiac Output

Altered heart At the end of 1. Monitor the patient’s 1. Assess for the patient’s At the end of 8
nagsasalita lang ako, r/t irregular atrial
structure 8 hours of vital signs baseline vital signs. hours of
parang nanghihina," contraction
nursing 2. Auscultate pulses, 2. Tachycardia is normally nursing
as verbalized by the secondary to
interventions, heart rate and present if there is poor interventions,
patient. structural heart Tricuspid
the patient rhythm. contractility of the the patient was
defect as valve
O: will be able 3. Palpate peripheral ventricles. able to gain
evidenced by regurgitation
to gain pulses. 3. May be used to show knowledge
VS – BP 130/80
tachycardia and
knowledge 4. Monitor urine decreased cardiac output. about actions
T 36.0 shortness of
Irregular atrial about actions output. 4. Possible indication of and

PR 120 breath
contraction and 5. Note changes in inadequate cerebral precautions to

RR 22 bpm precautions LOC or sensorium. perfusion. take for cardiac

to take for 6. Provide a quiet 5. Reduces emotional stress disease.

-Patient is awake,
Atrial
cardiac environment to for which increases heart rate
alert and is oriented.
fibrillation
disease. adequate rest. and BP.
-Irritated Goal: 7. Provide bedside 6. Decreased work load. Goal:

commode and 7. Can be used to indicate poor

-3/5 Overall Muscle Reduced At the end of At the end of 2
privacy. peripheral perfusion.
Strength ejection 2 days of days of nursing
8. Inspect skin for pain
fraction nursing Dependent: intervention,
- Decreased reaction
or pallor
intervention, the patient was
time 1. Helps reduce heart rate to
the patient Dependent:. able to have an
improve cardiac output.
-Body Weakness Tachycardia
will be able adequate
1. Administer
and Shortness Collaborative:
- Labs: to have an cardiac output
metoprolol as
of breath
adequate 1. For further assessment and as evidenced
PO2: 78 (80-100) prescribed by the
cardiac results that may have an by blood
Dilated right atrium physician.
output as affect on the patient. pressure and
along with a dilated Collaborative:
evidenced by pulse rate and
right ventricle with
blood 1. Collaborate with the rhythm within
hypocontractile
pressure and medical technologist normal
walls.
pulse rate for laboratory parameters.
Sodium: 129 (135- diagnostics and

155) results.

Potassium: 2.5 (3.5-

5.3)
 Nursing Care Plan # 3:
ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING NURSING RATIONALE EVALUATION

BASIS INTERVENTIONS

S: “Namamaga saka Excess fluid Renal congestion Objective: Independent: Independent: Objective:

namamanas ang mga volume related At the end of 8 1. Assess causative 1. Helps determine At the end of 8

paa ko,” as to compromised hours of and precipitating the appropriate hours of effective
Release of renin
verbalized by the regulatory effective factors interventions to nursing

patient. mechanism nursing 2. Monitor and record be done to the interventions the

secondary to interventions vital signs (BP, PR, patient. patient was able
Conversion of
O: heart failure as the client will RR and 2. Serves as a to demonstrate
renin to
-Patient is awake, manifested by be able to temperature), as baseline data of measures that can
angiotensin 1
alert and afebrile bipedal edema demonstrate well as input and the patient. be taken to treat
through
-Presence of +2 grade, 1-4 measures that output Changes in the or prevent excess
angiotensinogen
bipedal edema ( +2 mm indent, can be taken to 3. Assess degree of vital signs can fluid volume,

grade, 2-4mm somewhat treat or prevent bipedal edema cause further especially fluid

indent, somewhat deeper pit, Converted into excess fluid 4. Position patient to complications and dietary

deeper pit, angiotensin 2 volume, comfortable

disappears in 20-25 disappears 20- especially fluid position such as 3. Determines the restrictions and

secs) 25 secs) and dietary elevated legs amount of fluid medications.

Stimulates release
-Presence of restrictions and 5. Discuss the retained in the
of aldosterone and
wheezes on both medications. following body. Goal:
ADH
lungs upon measures to 4. Promotes At the end of 2

auscultation. Goal: prevent and lessen circulation as days of nursing

-Urine output is 120 Fluid retention At the end of 2 flyid volume well as to prevent interventions, the

cc for 6 hours (20 days of nursing excess: further stasis of patient was able

cc/hr) interventions, a. Advise patient to the fluid. to have a

Fluid overload the patient will elevate feet when 5. These health normovolemic
Labs:
be able to have sitting down teachings can status as
Sodium: 177
a b. Instruct patient help the patient to evidenced by
mmol/L (decreased) Fluid leaks to
normovolemic regarding cooperate for urine output
Potassium: 3.4 tissues
status as restricting fluid prevention of greater than or
mmol/L (decreased)
evidenced by intake complications equal to 30cc/hr.
Chloride: 87
urine output
Edema formation
-Vital signs: greater than or c. Encourage bed and health

BP: 130/80; equal to rest. promotion.

Temp: 36.0 C 30cc/hr. Dependent: Dependent:

PR: 120 bpm 1. Administer loop 1. Furosemide helps

RR: 22 bpm diuretics such as to decrease the

furosemide as amount of fluid

prescribed by the retained in the

physician. body, thus

Collaborative: decreasing

1. Collaborate with the edema.

family for further Collaborative:

instructions for the 1. Coordination

preventive measures with the family

and instructions members can

help the patient to

demonstrate self-
care interventions

to improve the

patient’s

condition.