NURSING CARE PLAN #1

ASSESSMENT EXPLANATION GOAL/OBJECTIVE INTERVENTION RATIONAL EVALUATION

OF THE
PROBLEM
Subjective: (Kindly refer to STO: After 8 hrs of Dx: STO:
“ marigatan nak nga pathophysiology) nursing intervention, *Monitored VS as *serves as a baseline *Fully met, after 8 hrs
aganges”, as the patient will be indicated especially data and basis for of nursing
verbalized by the able to sustain RR RR evaluating adequacy intervention, the
patient within normal range of ventilation patient sustained RR
as evidenced by: *auscultated breath *to prevent within normal range
Objective: *RR(12-20) sounds (crackles) respiratory distress as evidenced by:
*(+)productive cough *observed *to know proper *RR (20)
but unable to characteristics of intervention to relieve
expectorate the LTO: After 24 hrs of cough the cough LTO: Partially met,
sputum nursing intervention, after 24 hrs of nursing
*(+) crackles the patient will be Tx: intervention, the
*(+) restlessness able to maintain clear *rapport established *to have good patient slightly
*(+)cyanosis airway as evidenced relationship for fast maintained clear
*(+) flatness upon by: recovery airway as evidenced
percussion of the *(-)crackles *elevated head of bed *to facilitate by:
lungs *(-)cough with and assist client to respiratory function *(+)crackles
*(+) Vocal fremituse greenish sputum assume comfort *(+)cough with
is moderate *(-)restlessness position greenish sputum
*VS *(-)cyanosis *Promoted rest and *to prevent fatigue *(-)restlessness
BP:110/70mmHg *RR:12-20 comfort *(+)cyanosis
RR:28 bpm *ensure safety *to provide patient’s *RR:20
PR:89 bpm safety as one of his
T:37 °C basic needs
Factors:
Nursing Diagnosis: *Keep the *to ↓ precipitating STO-Goal met due to
*Ineffective airway environment free factors cooperation and
clearance r/t from dust participation of the
Retained secretions patient to the
secondary to implementation of
excessive mucus nursing intervention.
production
Edx: LTO:
*to help patient *Goal is partially met
*Encouranged expectorate sputum due to insufficient
adequate hydration easily time as well as patient
such as ↑ fluid intake easily get tired though
cooperative.
NURSING CARE PLAN # 2

ASSESSMENT EXPLANATION GOAL/OBJECTIVE INTERVENTION RATIONAL EVALUATION

OF THE
PROBLEM
Subjective: (kindly refer to STO: After 8 hrs of Dx: STO: Fully met, after
“ marigatan nak nga pathophysiology) nursing intervention, *Monitord V/S as *serves as a baseline 8 hours of nursing
aganges”, and added, the patient’s indicated especially data and basis for intervention, the
“haanak unay fingernail will change RR evaluating adequacy patient’s fingernails
makaanges” as color from cyanotic to of ventilation change color from
verbalized by the pinkish *low Hgb levels cyanotic to pinkish
patient *Monitored reduce the uptake of
hemoglobin levels O2 at the alveolar
Objective: LTO: After 24 hrs of capillary membrane LTO: Partially met,
*presence of dyspnea nursing intervention, and O2 delivery to after 24 hrs of nursing
when coughing the patient will be tissues intervention, the
*(+) cyanosis of the able to maintain patient slightly
fingernails optimal gas exchange maintained optimal
*VS: as evidenced by: Tx: *to have good gas exchange as
BP:110/70 mmHg *(-)dyspnea when *Rapport established relationship for fast evidenced by:
RR:28 bpm coughing recovery *(+)dyspnea
PR:88 bpm *(-)cyanosis of the *to give adequate *(-)cyanosis of the
T: 36.9°C fingernails *provide supplemental ventilation fingernails
*RR:29 oxygen at 2-3pm via *RR:20
nasal cannula *to prevent fatigue
Nursing Diagnosis: *promoted rest and Factors:
*Impaired Gas comfort *to provide patient’s STO-Goal is met due
exchange r/t altered *ensure safety safety as one of his to cooperation and
oxygen supply basic needs participation of the
* to reduce irritant patient to the
effect of dust on implementation of
*keep the environment airway nursing intervention
free from dust
LTO-Goal is partially
 met due to
insufficient time and
*Administered the patient was
bronchodilators and cooperative but get
anticholinergic such as: tired easily.
 Salbutamol + *salbutamol affect
ipratropium the sympathetic
nervous system
dilating the walls of
the bronchial tubes;
ipratropium acts to
inhibit the effect of
acetylcholine that
results in
bronchodilation

Edx:
*Encouraged frequent *promote optimal
position changes and chest expansion and
coughing exercise drainage of secretions
*Smoking
*discussed about the termination improve
importance of smoking lung expansion
termination
NURSING CARE PLAN #3

ASSESSMENT EXPLANATION GOAL/OBJECTIVE INTERVENTION RATIONAL EVALUATION

OF THE
PROBLEM
Subjective: (kindly refer to STO: After 8 hrs of Dx: STO: Partially met, after
“Nauma ak pathophysiology) nursing intervention, the *Monitored V/S as *serves as baseline 8 hrs of nursing
ngaruden ti patient will increase his indicated data intervention, the patient
arozcaldo ken food uptake as evidence * review lab result *evaluate and ↑his food intake as
champorado’n nga by demand of foods (serum albumin) monitor evidenced by demand of
kinanaun ko nga effectiveness of food however not enough
kankanen”, as nutritional therapy to sustain his body needs
verbalized by the *due to sputum
patient *assessed dietary production patient
habits as well as is often lacking
Objective: recent food intake interest in food
Weight:47kgs
*height:5’7” LTO:Goal unmet, after
*BMI: 12kg/m2 LTO: After 2 days of *to have good 2days of nursing
*VS: nursing intervention, the Tx: relationship for intervention, the patient
BP:110/70 mmHg patient will display *rapport established fast recovery didn’t display weight gain
RR:28 bpm weight gain as manifested *to give unpleasant as manifested by:
PR:88 bpm by: *give frequent oral taste that might
T:37°C  BMI:18.5kg/ m2 care, remove cause lack of food  BMI:12kg/ m2
*(+)productive  Weight:48kgs expectorated interest  Weight:47kgs
cough secretions readily
Factors:

*helps reduce *STO- partially met due

Nursing Diagnosis: Edx: fatigue during to presence of cough
*encouraged a rest mealtime provides
*imbalanced period for 1 hr opportunity to LTO-unmet due to
nutrition: less than before and after ↑total caloric insufficient time and
body requirements meals and provided intake there’s still presence of
r/t increase mucus frequent small cough which is the
production and lack feedings precipitating factor in
of interest in foods lack of interest in food
*it might produce
abdominal
enlargement,
*instructed patient to which hinder
avoid gas producing abdominal
foods and carbonated breathing and
drinks diaphragmatic
movement which
can ↑dyspnea

NURSING CARE PLAN #4

ASSESSMENT EXPLANATION GOAL/OBJECTIVE INTERVENTION RATIONALE EVALUATION

 OF THE
PROBLEM
Subjective: (kindly refer to STO: After 8 hrs of Dx: STO: Fully met, after
pathophysiology) nursing intervention, 8 hrs of nursing
“sumaksakit daytoy the pain will ↓from *Monotored V/S as *to evaluate patient’s intervention, the pain
tubo nga ingkabil da 5/10 to 2/10 indicated response and to serve ↓from 5/10 to 2/10
ditoy bara lalonu as baseline date.
aguyek nak ken nu *to know right LTO:Partially met,
kumaro diyay asthma LTO:After 24 hrs of *assessed measures to be after 24 hrs of nursing
kun” as verbalized by nursing intervention, characteristics, implemented intervention, the pain
the patient, the pain will ↓from location, severity of ↓ from 5/10 to 2/10
Intermittent stubbing 5/10 to 0/10 pain
pain with rate of 5/10

Objective: Tx:
*s/p CTT insertion in *to have a good
the right lateral *rapport established relationship for fast
*(+)grimace and recovery
guarding behavior *to prevent fatigue
*(+)restlessness *promoted rest and
*VS: comfort *to provide patient’s
BP:110/80 mmHg *ensure safety safety as one of his
PR:28 bpm basic needs.
RR: 87 bpm
T: 36.8°C *to maintain
*administered acceptable level of
Nursing Diagnosis: NSAIDS such as: pain
 Tramadol
*acute pain r/t lung
tissue trauma
secondary to CTT
insertion

Edx:
 *to assess if what
*encouraged intervention should be
verbalization of implemented
feelings about pain

NURSING CARE PLAN #5

ASSESSMENT EXPLANATION GOAL/OBJECTIVE INTERVENTION RATIONAL EVALUATION
OF THE
PROBLEM
Subjective: (kindly refer to the STO: After 8 hrs of Dx: STO:goal met, after
pathophysiology) nuring intervention, 8hrs of nursing
“nagbiit nak nga the patient will *noted reports of *to establish patient’s intervention, the
mabannog lalo nu demonstrate ↓signs of dyspnea and fatigue needs and facilitates patient
apanak jay CR isu activity intolerance as choice interventions demonstrated↓signs
nga ni baket q nga ag- evidenced by: of activity intolerance
CR”, as verbalized by Tx: as evidenced by:
the patient *(-)cyanosis
*rapport established *to have good *(-)cyanosis
relationship for fast
Objective: recovery
LTO:After 2 days of *assisted patient to *to facilitate LTO: partially met
*(+)fatigue nursing intervention, have comfortable respiratory function after 2 days of nursing
*(+)dyspnea the patient will position to rest intervention, the
(+)cyanosis achieved measurable *assist with client self *minimizes patient slightly
↑in activity care activities exhaustion and help achieved
intolerance as balance oxygen measurable↑in
Nursing Diagnosis: evidenced by: supply and demand activity tolerance as:
Edx: (+)fatigue
*activity intolerance *(-)fatigue (-)cyanosis
r/t imbalanced oxygen (-)cyanosis *explained *bed rest maintained (+)dyspnea
supply and demand (-)dyspnea importance of rest and to reduce fatigue and
necessity for dyspnea
balancing activities
with rest