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 perfusion breathing will be fowler’s) position. It Long Term:
Cues: inequality; related to lessened. maximize lung > Pt. was able to
>Increased RR – 29 retained secretions as expansion thus sustain verbalize in
>Cardiac rate - 108 evidenced by Long Term: open airway understanding of the
>Abdominal breather tachycardia, tachypnea, >After 1 day Pt will >Advised the pt to disease and its course
>With crackles crackles, wheezing, and demonstrate keep calm during of treatment
> With wheezes cyanosis improvement in episodes of breathing
>With circum oral ventilation and adequate difficulty to prevent
cyanosis oxygenation within aggravation of the
>With nasal flaring normal limits and having disease
absence symptoms of >Encouraged deep
respiratory distress controlled breathing
> After 3 days Pt will exercise. It promotes
be able to verbalize optimal chest expansion
understanding regarding
factors that would Dependent:
contribute to > O2 inhalation via
exacerbation of disease NC as ordered by
and will participate in physician.
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 will maximize lung
>With crackles tracheobronchial tree as 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 proper prevent measure.
> After 3 days Pt will disposal of secretions.
be demonstrate
behavior to improve Dependent:
adequate lifestyle >Nebulize with
changes to improve Salbutamol, Combivent
adequate oxygenation & as ordered by attending
prevent exacerbation of physician
the disease.
 PROBLEM DIAGNOSIS PLANNING INTERVENTION EVALUATION

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

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