XI.

Nursing Care Plan

PROBLEM DIAGNOSIS PLANNING INTERVENTION EVALUATION

“Hirap akong Nursing Diagnosis: Short Term: Independent: Short Term:

huminga”, as >Impaired gas >Within 15 mins of >Elevate the head >Goal partially met
verbalized by the pt. exchanged 2○ to duty, difficulty of of the bed 45○ (semi-
ventilation and breathing will be fowler’s) position. It Long Term:
Cues: perfusion inequality; lessened. maximize lung > Pt. was able to
>Increased RR – 29 related to retained expansion thus sustain verbalize in
>Cardiac rate - 108 secretions as evidenced Long Term: open airway understanding of the
>Abdominal breather by tachycardia, >After 1 day Pt will >Advised the pt to disease and its course
>With crackles tachypnea, crackles, demonstrate keep calm during of treatment
> With wheezes wheezing, and cyanosis improvement in episodes of breathing
>With circum oral ventilation and difficulty to prevent
cyanosis adequate oxygenation aggravation of the
>With nasal flaring within normal limits and disease
having absence >Encouraged deep
symptoms of respiratory controlled breathing
distress exercise. It promotes
> After 3 days Pt will optimal chest expansion
be able to verbalize
understanding Dependent:
regarding factors that > O2 inhalation via
would contribute to NC as ordered by
exacerbation of disease physician.
and will participate in
treatment regimen
PROBLEM DIAGNOSIS PLANNING INTERVENTION EVALUATION

“Inuubo ako”, as Nursing Diagnosis: Short Term: Independent: Short Term:

verbalized by the pt. >Ineffective airway >Within 4 hours of >Elevate the head >Goal partially met
clearance related to duty phlegm will be of the bed 45○ (semi- >Difficulty of
Cues: increase production of liquefy & expectorated fowler’s) position. It breathing was lessened
>Increased RR – 29 mucus in the & further complication maximize lung
>With crackles tracheobronchial tree as will be prevented.; expansion thus sustain Long Term:
>With chest pain evidenced by productive open airway > Pt. was able to
>With back pain cough, crackles, chest Long Term: >Advised to do understand adherence
pain & back pain. >After 3 days of bronchial tapping to to the therapeutic
duty, pt will be able to loosen secretions & for regimen.
verbalized better expectoration. >Pt. Was able to
understanding of >Encouraged to understand proper
condition, therapy increase fluid intake if management of his
regimen and side effect not contraindicated. condition & follow the
of med. >Emphasized prevent measure.
> After 3 days Pt will proper disposal of
be demonstrate secretions.
behavior to improve
adequate lifestyle Dependent:
changes to improve >Nebulize with
adequate oxygenation & Salbutamol, Combivent
prevent exacerbation of as ordered by attending
the disease. physician
PROBLEM DIAGNOSIS PLANNING INTERVENTION EVALUATION

“Nanghihina ako”, Nursing Diagnosis: Short Term: Independent: Short Term:

as verbalized by the >Nutritional >Within 4 hours of >Encouraged to eat >Goal met
pt. imbalanced less than duty patient will be adequate nutritious food
body requirements regained body strength like green leafy Long Term:
Cues: related to inadequate & loss of appetite will be vegetables, fishes and >Pt. Was able to
>Loss of appetite intake of nutritious food relieved. fruits rich in vitamin C to understand having
>Productive cough to meet metabolic boost immune system. proper nutrition and the
needs secondary to Long Term: >Advised to have importance of having
underlying disease as >After 2 days of adequate rest & sleep, it adequate rest & sleep,
evidenced by loss of duty patient will be helps to regained body regarding to his health
appetite & body demonstrate strength. condition
weakness improvement in appetite
& proper nutrition. Dependent:
>(Dibencozide)
Heraclene for appetite
stimulants as ordered
by attending physician