VI.

NURSING CARE PLAN

Date: October 15, 2018
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective Data: After 4 hours of Independent: The goal is met.
nursing
“Nahihirapan akong Ineffective airway intervention, patient Elevate head of the To take After 4 hours of
huminga.” As clearance related to will be able to: bed/ change position advantage of nursing intervention,
verbalized by the excessive mucus every 2 hours and gravity patient verbalized
patient. secondary to Demonstrate prn. decreasing “Nakakahinga na po
pneumonia reduction of pressure on the ako nang maayos.”
Objective Data: congestion with diaphragm and
breath sounds clear enhancing Maintained airway
PR: 67 bpm and improve drainage patency
RR: 13 cpm oxygen exchange. of/ventilation
BP: 70/50 of different Demonstrated
T: 36.6 lung segment reduction of
O₂SAT: 95 congestion with
breath sounds clear,
Monitor v/s signs Used as a respirations
With series of especially respiratory baseline data noiseless, improve
productive cough rate, note for and to evaluate oxygen exchange
respiratory distress degree of
With DOB and compromise
crackles on both
lung fields
Conduct health Breathing
teaching on breathing techniques can
techniques help in lung
expansion and
mobilize
secretions
 Administer Ceftriaxone
Ceftriaxone and lowers
Salbutamol as per respiratory
Doctor’s order infections to
the client and
Salbutamol
helps in the
management
of reversible
bronchospasm
to the client

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

 Subjective Data:
After 3 hours of
Activity intolerance intervention, patient Assess vital signs Used as a The goal is met.
“Nanghihina po d/t general malaise will be able to: baseline data
katawan ko dahil The patient
hindi po ako verbalized “Malakas
makapahinga nang Report improved Encourage to drink Adequate na po ang
maayos.” As sense of energy fluids water intake pakiramdam ko.
verbalized by the can reduce the Hindi na po ako
patient. feeling of nanghihina.”
dehydration
which also
causes fatigue

Objective Data:
Provide a sound and Having a
comfortable conducive
PR: 98 environment environment
RR: 14 cpm conducive for resting. can promote
BP: 80/50 rest
T: 37.1°C
O₂SAT: 96

Promote Having an
bedrest/activity adequate sleep
limitation increases
conservation
of energy

Date: October 15, 2018