NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATIO N

Subjective:

Masakit ang dibdib ko as verbalized by patient.

Acute pain r/t localized inflammation and persistent cough.

After 4 hours of
nursing interventions, the patient will display patent airway with breath sounds clearing and absence of dyspnea.

Independent:

After 4 hours
Elevate head of the bed, change position frequently. Lowers diaphragm, promoting chest expansion and expectoration of secretions. Deep breathing facilitates maximum expansion of the lungs and smaller airways. Coughing is a natural self cleaning mechanism. Splinting reduces chest discomfort, and an upright position favors deeper, more forceful cough effort. Fluids especially warm liquids aid in mobilization and expectoration of secretions. of nursing interventions , the patient will display patent airway with breath sounds clearing and absence of dyspnea.

Objective:

Assist patient with deep breathing exercises.

Use of accessory muscle.

Dyspnea

Demonstrate or help patient learn to perform activity like splinting chest and effective coughing while in upright position.

Fatigue.

V/S taken as follows:

Force fluids to at least

3000 ml per day and offer warm, rather than cold fluids.

T: 37.3 P: 80 R: 25 Bp: 120/80

Collaborative:

 Administer
medications as prescribe: mucolytics or expectorants.

Aids in reduction of
bronchospasm and mobilization of secretions.

Provide supplemental fluids.

Fluids are required to replace losses and aid in mobilization of secretions.

ASSESSMEN T

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective: (None)

Impaired gas exchange related to

Short Term:

Establish Rapport

To gain pts trust

Short Term:

After 4 hours of NI, the pt will participate in treatment regimen within level of ability

Monitor Vital Signs

To obtain baseline data

The pt shall have

Objective:

alveolar capillary

Restlessn ess

membrane changes secondary to

Note RR, use of accessory muscles & pursed lip breathing

To evaluate degree of compromise

participated in treatment regimen within

Irritability

Auscultate breath sounds

community acquired Long Term:

To determine presence of productive cough

level of ability

Long Term:

Diaphores is

pneumonia After 4 days of

Evaluate pulse
oximetry to determine oxygenation

To assess for respiratory insufficiency The pt shall For comparative purposes have demonstrated improved To maintain patent airway ventilation and absence of For optimal lung expansion symptoms of respiratory distress

Productiv e Cough

NI, the pt will demonstrate improved Review Pertinent laboratory data

Adventitio us breath sounds

ventilation and absence of symptoms of Elevate HOB

Confusion

respiratory distress

Reposition client

Abnormal

Instruct deep breathing and coughing exercises

For drainage of secretions

SHERRY CILLE B. BAYLON

BSN 4 BLOCK 4 (Group 1)