NURSING CARE PLAN

Client: N. D. Age: 39 Gender: Male

Medical Diagnosis: Community Acquired Pneumonia, Moderate Risk, PTB

PRIORITY #1: Ineffective Airway Clearance related to thick tenacious secretions and airway obstruction as evidenced by wheezes upon
auscultation, shallow respiration, and tachypnea.

ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION

Short-term goal Independent After doing the necessary
Subjective nursing interventions and
Client verbalized, After 6 hours of nursing teachings:
“Nahihirapan ako huminga intervention: 1) Monitor VS every 2 hours 1) To assess baseline data.
dahil parang nakadikt na ata
ang plema ko sa aking baga.” >Client will be able to cough 2) Encouraged patient to sleep 2) Promotes maximal lung >Client’s SO responded to the
out effectively and clear airway with high-Fowler’s or semi- expansion and decreases health teachings performed
>non-productive cough secretions. Fowler’s position. respiratory distress. regarding activity modification
for the client to prevent fatigue.
>DOB 3) Advise patient to turn 3) Repositioning aids in the
patient every 2 hours and as drainage of pulmonary
Objective >Client’s SO will participate in needed. secretions.
the treatment regimen. >Client was able to cough out
>Vital signs effectively
T:36.5 4) Teach client to maintain 4) To help in the thinning of
PR:94 adequate hydration by drinking secretions.
RR:22 >Client will exhibit signs of at least 1-2 ml of fluid/day (if >Exhibited signs of decreased
BP:85/60 comfortability and absence of not contraindicated). irritation
irritation.
>inability to cough effectively 5) Taught and supervised 5) To conserve energy and >Decreased difficulty of
Long-term goal effective coughing techniques. effectively cough out breathing
>wheezes noted upon secretions
auscultation >Client will maintain patency
of airway and will have clear 6) Performed chest physio- 6) Chest physiotheraphy >Shows understanding of the
>with respiratory distress upon breath sounds. therapy. facilitates secretion removal. goal towards activity
exertion modification.

>positive chest retractions 7) Monitor airway regularly for 7) For the assessment of the
patency by auscultation. required therapeutic regimen
for the client.
 8) Assisted in administering IV 8) To improve ventilation and
antibiotics and bronchodilators maximizes air exchange.
as ordered.

9) Instructed client/family to 9) Indicates bronchial tubes are

notify nurse if the client is blocked with mucus, leading to
experiencing shortness of hypoxia and hypoxemia.
breath or air hunger.

10) Instructed client/family 10) Promotes client and client

regarding medications and SO’s independence and
symptoms of adverse effects to adherence to the prescribed
report to nurse or physician. therapeutic regimen.

PRIORITY #2: Ineffective Breathing Pattern related to alteration of the normal oxygen saturation as evidenced by
recurrence of DOB upon exertion

ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Short-term goal Independent
After doing the necessary
>Client verbalized, “May mga At the end of this shift, the 1) Inspected the throat, 1) To determine the cause of nursing interventions and
times na hirap talaga akong client will: describing the color, presence breathing problems This will teachings, the client:
huminga kahit wala naman of exudates, or swelling. provide a data that could be
akong ginawa.” used to evaluate the proper
>Be able to verbalize factors intervention that the client >Verbalized awareness of
“Pagkatapos ko maglakad ng that causes his dyspnea. needs. factors that causes his
mahaba madalas nahihirapan breathing problems
na ko huminga.” 2) Encouraged the client to 2) To help in expectorating the
increase the fluid intake. mucus secretions.
>Easy fatigability
>Unproductive cough 3) Identified factors that causes 3) This varies with each >Verbalized understanding
>Verbalize lifestyle changes his breathing impairment individual and situation. of the given information.
Objective that he will do to avoid
>Vital signs recurrence of dyspnea. 4)Auscultate his chest 4) To evaluate the character of
T:36.5 breath sounds
PR:94 >Verbalized that he will
RR:22 5) Reviewed the results of his 5) To assess the cause of adhere to the prescribed
BP:85/60 laboratory testing like chest dyspnea and other respiratory pharmacological regimen.
x-ray,02 saturation, and problems
>Shallow breathing through >Understand the health hematology.
his mouth teachings >Demonstrated use of
>Nasal flaring 6) Evaluate his cough and 6) Secretions obstruct airways relaxation skills.
>Facial grimacing presence of secretions which causes breathing
>Respiratory depth changes impairments.
>Weakness in appearance
>Wheezes noted upon 7)Provided health teachings >Responded to the health
auscultation such as: teaching
-using of pursed-lip breathing >To assist the client in
technique controlling dyspnea.
>Verbalize appropriate coping >Verbalized appropriate
behaviors -activity modification >to reduce fatigue coping behaviors and
lifestyle changes that he will
do.
8) Encouraged the client to 8)To limit fatigue that will
limit activities and avoid cause dyspnea and SOB
smokers, exposure to dust,
perfumes, animals, etc.

9) Facilitated the use of 9) To lessen respiratory

nebulizer distress
 PRIORITY #3: Readiness for enhanced knowledge as evidenced by verbalization of interest in health teachings regarding
diet/activity modification
ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Short term goal:
After doing the necessary
>Verbalization of questions: At the end of this shift, the nursing health teachings,
“Gusto ko sana malaman client will: 1) Asked client of what’s his 1) To identify best approaches the client has:
kung ano ang mga pwede at preferred methods of learning. to facilitate learning progress.
diko pwedeng gawin
pagkalabas dito? >Verbalize that he will use >Responded to the learning
given information in all 2) Encouraged client to explore 2) To promote ongoing plan and actions performed.
>Expresses interest in applicable areas including on additional learning learning at his own pace.
learning environmental and personal. resources like internet and
other medical books and >Provided a positive
>Verbalized previous references. feedback with the instructor.
experiences regarding his
disease. >Verbalize understanding of 3)Teach client the following:
the provided information. -Stay calm as possible during -Anxiety during an asthma >Verbalized understanding
>Easy fatigability asthma attack attack can further potentiate of the given info.
the exacerbation.
Objective: -Pace activities. -Fatigue can increase the work
of breathing and decrease
>Patient for discharge >Use the information gained to cough effectiveness.
meet her health care goals
>Alert and coherent -Avoid smoking, 2nd hand -Avoids recurrence of
smoking symptoms
>Ambulatory
-Encourage increased fluid -Fluids are lost from mouth
>Vital signs intake (uo to 3000ml a day) if breathing and oxygen therapy.
T:37.7 there are no contraindications Maintaining hydration
PR:94 such as cardiac or renal increases ciliary action to
RR:26 disease. remove secretions and
BP:140/90 decreases viscosity of
secretions.
Fracture, Open, Segmented Tibia, Right; Fracture, Closed, M-D3, Fibula, Right
Priority 1: Acute pain related to soft tissue injury and wounds due to an external fixator in place as evidenced by client's
verbalization of discomfort and irritability.
Assessment
Subjective:
Pain scale of 3/10
"Kumikirot siya kahit na
hindi nagagalaw."
Pain is localized in the
surgical site only.
Objective:
Vital signs as are follows:
T=36.9 PR=88 RR=20
BP= 115/70
Client’s skin is cold.
Surgical incision is well
coaptated. Non-
erythematus. Absent
dehiscence and
evisceration, wound is not
bleeding and has no foul
odor.
Patient is moaning and
restless.
Facial grimaces are
observable during pain
exacerbation.
Outcome Identification Intervention Rationale Evaluation
After the necessary Assess for pain or Provides baseline for At the end of the 8hrs
interventions the patient discomfort. assessing changes in nursing care, the patient
will: pain level and evaluating has:
interventions.
Patient verbalizes pain Verbalized decrease in
relief or an acceptable Assess the patient's Guides in the intensity of pain from
reduction in pain. description of pain. appropriate intervention 7/10 to 4/10.
applicable to his
Patient appears condition. Patient demonstrated
comfortable. relaxation techniques
Administer analgesics as For pain relief. and diversional activities
prescribed. (Analgesics are more that enhance pain relief.
effective if administered
early in the pain cycle;
relief of pain)
.
Provide health teachings Use of these strategies
on other non- along with analgesia
pharmacologic may produce more
interventions like deep effective pain relief
breathing technique and
diversional activities.
Assess effectiveness of Patient has a right to
pain-relieving effective pain relief. It is
interventions not determined to be
effective until the patient
indicates that it is
acceptable.
Priority 2: Impaired physical mobility related to external fixation device in place as evidenced by inability to move
purposefully within physical environment.
Assessment
Subjective:
"Sabi ng doctor bawal daw
igalaw muna itong kanang
hita ko."
"Medyo mahirap talaga
kapag dika nakakagalaw
galaw ng ayon sa gusto
mo."
Objective
Vital signs as are follows:
T=36.9 PR=88 RR=20
BP= 115/70
Client’s skin is cold.
Objective:
Patient is confined to his
bed, non-ambulatory
External fixation device
attached to his right leg
Surgical incision is well
coaptated; Non-
erythematus; Absent
dehiscence and
evisceration; wound is not
bleeding and has no foul
odor.
Outcome Identification Intervention Rationale Evaluation
After the necessary Assess for ROM of Optimal ROM is critical At the end of the 8hrs
interventions the patient unaffected parts for movement and nursing care, the patient
will: proximal and distal to necessary for has:
the immobilization rehabilitation.
Patient maintains device Patient showed
maximum mobility participation in doing the
within prescribed Determine the type of Patient may require a interventions and said
restrictions. mobility supports the cane, walker, or crutches that they were all
patient will require in to enhance ambulation. beneficial for the
anticipation of enhancement of his
discharge. mobilization.
. Assess muscle strength The rehabilitation Client said that he'll
in all extremities. program will be geared make sure to do those
toward maximizing exercises whenever
strength in the possible.
unaffected extremities
Administer analgesics as and maintaining as much
prescribed. strength as possible in
the affected or
immobilized extremity.
Encourage isometric, Exercise prevents
active, and resistive muscle atrophy and
ROM exercises to all maintains adequate
unaffected joints on a muscle strength required
schedule consistent with for mobility.
the rehabilitation
program and as
tolerated.
Perform flexion and These exercises serve to
extension exercises to maintain mobility.
proximal and distal
joints of the affected
 extremity, when
indicated.

Apply splint to support A splint prevents

foot in neutral position. footdrop in patients
immobilized in external
fixation devices.

Place personal things This will encourage the

like tissue paper, patient to have
alcohol, etc within easy independence in doing
reach for the patient. things within the
restrictions of his
immobility.

Priority 3: Risk for constipation related to immobility and to the client's delaying the passing of his stools at night as
evidenced by his verbalization of being uncomfortable defecating on his bed pan at daytime due to no privacy.
Assessment Outcome Identification Intervention Rationale Evaluation

Subjective: Assess usual pattern of "Normal" frequency of

Patient verbalized, "Pang- After the necessary elimination; compare passing stool varies from At the end of the 8hrs
apat na araw ko na ngayon interventions the patient with present pattern, twice daily to once every nursing care, the patient
na hindi nakadumi." will: include size, frequency, third or fourth day. It is has:
color, and quality. important what is
"Nakakaramdam ako na Patient passes soft, "normal" to each Patient was able to know
madudumi na pero pag formed stool at a individual. the factors that could
may bedpan na hindi frequency perceived as cause being constipated.
naman matutuloy. normal by the patient. Evaluate laxative use , Chronic use of laxative
type, and frequency causes rebound
"Normally every day Patient or caregiver constipation. Over time Patient was able to
naman ako nagbabawas." verbalizes measures that the colon becomes determine that his
will prevent recurrence atonic and distended. immobility has
Objective: of constipation. contributed to the
Hypoactive bowel sound 2- Evaluate usual dietary Change in meal time, decreased motility of his
3 bowel sounds per 5 habits, eating habits, type of food, disruption GI tract
minutes eating schedule, and of usual schedule, and
liquid intake. anxiety can lead to
Abdomen does not appear . constipation.
to be distended; soft and
non-tender upon palpation
Evaluate current Drugs that can cause
medication usage that constipation include the
may contribute to following: narcotics,
constipation. antacid with calcium or
aluminum base,
antidepressants,
anticholinergics,
antihypertensives,
general anesthetics,
hypnotics, and iron and
calcium supplements.
Assess the need for Many individuals report
privacy for elimination. that being away from
home limits their ability
to defecate
PRIORITY 3: Readiness for enhanced knowledge as evidenced by verbalization of interest in health teachings regarding
diet/activity modification
Prosthetic Joint Infection, Left Hip, Post-traumatic Osteomyelitis, Resolved Left Femur

Priority 1: Acute pain related to surgical incision for his prothethic implants and wounds for the external fixator as
evidenced by client's verbalization of discomfort and irritability.
Assessment Outcome Identification Intervention Rationale Evaluation

Subjective:
Pain scale of 7/10
Pain is localized in the
surgical site only.
Vital signs as are follows:
T=36.2 PR=120 RR=23
BP= 120/70
Client’s skin is cold.
Subjective:
After the necessary Assess for pain or Provides baseline for At the end of the 8hrs
interventions the patient discomfort. assessing changes in nursing care, the patient
will: pain level and evaluating has:
interventions.
Patient verbalizes pain Verbalized decrease in
relief or an acceptable Assess the patient's Guides in the intensity of pain from
reduction in pain. description of pain. appropriate intervention 7/10 to 4/10.
applicable to his
Patient appears condition. Patient demonstrated
comfortable. relaxation techniques
Administer analgesics as For pain relief. and diversional activities
Surgical incision is well
coaptated. Non-
erythematus. Absent
dehiscence and
evisceration, wound is not
bleeding and has no foul
odor.
Patient is moaning and
restless.
Facial grimaces are
observable during pain
exacerbation.
Priority 2: Impaired physical mobility related to external fixation device as evidenced by inability to move purposefully
within physical environment.
Assessment
Subjective:
Pain scale of 7/10
Pain is localized in the
surgical site only.
Vital signs as are follows:
T=36.2 PR=120 RR=23
BP= 120/70
Client’s skin is cold.
Subjective:
Patient is confined to his
bed, non-ambulatory
External fixation device
attached to his left leg
prescribed. (Analgesics are more that enhance pain relief.
effective if administered
early in the pain cycle;
relief of pain)
.
Provide health teachings Use of these strategies
on other non- along with analgesia
pharmacologic may produce more
interventions like deep effective pain relief
breathing technique and
diversional activities.
Assess effectiveness of Patient has a right to
pain-relieving effective pain relief. It is
interventions not determined to be
effective until the patient
indicates that it is
acceptable.
Outcome Identification Intervention Rationale Evaluation
After the necessary Assess for ROM of Optimal ROM is critical At the end of the 8hrs
interventions the patient unaffected parts for movement and nursing care, the patient
will: proximal and distal to necessary for has:
the immobilization rehabilitation.
Patient maintains device Patient showed
maximum mobility participation in doing the
within prescribed Determine the type of Patient may require a interventions and said
restrictions. mobility supports the cane, walker, or crutches that they were all
patient will require in to enhance ambulation. beneficial for the
anticipation of enhancement of his
discharge. mobilization.
. Assess muscle strength The rehabilitation Client said that he'll
in all extremities. program will be geared make sure to do those
toward maximizing exercises whenever
strength in the possible.
unaffected extremities
Surgical incision is well Administer analgesics as and maintaining as much
coaptated. Non- prescribed. strength as possible in
erythematus. Absent the affected or
dehiscence and immobilized extremity.
evisceration, wound is not
bleeding and has no foul Encourage isometric, Exercise prevents
odor. active, and resistive muscle atrophy and
ROM exercises to all maintains adequate
unaffected joints on a muscle strength required
schedule consistent with for mobility.
the rehabilitation
program and as
tolerated.

Perform flexion and These exercises serve to

extension exercises to maintain mobility.
proximal and distal
joints of the affected
extremity, when
indicated.

Apply splint to support A splint prevents

foot in neutral position. footdrop in patients
immobilized in external
fixation devices.

Place personal things This will encourage the

like tissue paper, patient to have
alcohol, etc within easy independence in doing
reach for the patient. things within the
restrictions of his
immobility.
Priority 3: Constipation related to immobility as evidenced by frequent but nonproductive desire to defecate.
Assessment Outcome Identification Intervention Rationale Evaluation

Subjective: Assess usual pattern of "Normal" frequency of

Patient verbalized, "Pang- After the necessary elimination; compare passing stool varies from At the end of the 8hrs
apat na araw ko na ngayon interventions the patient with present pattern, twice daily to once every nursing care, the patient
na hindi nakadumi." will: include size, frequency, third or fourth day. It is has:
color, and quality. important what is
"Nakakaramdam ako na Patient passes soft, "normal" to each Patient was able to know
madudumi na pero pag formed stool at a individual. the factors that could
may bedpan na hindi frequency perceived as cause being constipated.
naman matutuloy. normal by the patient. Evaluate laxative use , Chronic use of laxative
type, and frequency causes rebound
"Normally every day Patient or caregiver constipation. Over time Patient was able to
naman ako nagbabawas." verbalizes measures that the colon becomes determine that his
will prevent recurrence atonic and distended. immobility has
Objective: of constipation. contributed to the
Hypoactive bowel sound 2- Evaluate usual dietary Change in meal time, decreased motility of his
3 bowel sounds per 5 habits, eating habits, type of food, disruption GI tract
minutes eating schedule, and of usual schedule, and
liquid intake. anxiety can lead to
Abdomen does not appear . constipation.
 to be distended; soft and
non-tender upon palpation Evaluate current
medication usage that
may contribute to
constipation.
Drugs that can cause
constipation include the
following: narcotics,
antacid with calcium or
aluminum base,
antidepressants,
anticholinergics,
antihypertensives,
general anesthetics,
hypnotics, and iron and
calcium supplements.

Assess the need for Many individuals report

privacy for elimination. that being away from
home limits their ability
to defecate

Priority 1: Hyperthermia related to disease process, humid environment as evidenced by elevated temperature of 38 °C, warm skin, tachypnea, and tachycardia.

Assessment Planning Intervention Rationale Evaluation

SUBJECTIVE:
“Parang mainit ang loob ng After performing the >Monitor the client’s >Note sudden changes in After performing the
katawan ko” nursing interventions, client temperature. client’s body temperature nursing interventions:
will:
OBJECTIVE: >Note presence or >Evaporation is decreased >Client’s caregiver
>Vital Signs taken as > Maintain core absence of sweating as by environmental factors of demonstrated how to do
follows: temperature within normal body attempts to increase high humidity and high tepid sponge bath
T: 38 °C range. heat loss by evaporation, ambient temperature. especially when fever
PR: 108 conduction, and diffusion comes back.
RR: 24 > Demonstrate behaviors
BP: 110/70 to monitor temperature. >Promote surface cooling >Heat lost by radiation and >After 2 hours, client’s
> elevated temperature of by means of undressing or conduction temperature dropped to 36
38°C and RR is 24 >Significant Others would removing extra clothing °C from 38 °C
 >tachycardia
>tachypnea
> Skin is warm to touch
> Exhibited signs of
restlessness/weakness
demonstrate proper way of
doing tepid sponge bath
>Promote a cool
environment like the use of
electric fan
>Teach client or caregiver
on how to do a tepid
sponge bath
>Heat is lost by convection
>Heat loss by conduction
and evaporation especially
in the groin and axillae
because these are areas of
high blood flow

>Discuss importance of >Prevent dehydration

adequate fluid intake

COLLABORATIVE:
>Administer antipyretics:
Drug: Paracetamol >Treat underlying cause
Drug Dosage:
* 300 mg/IV if T ≥ 38.8°C
* 500mg/tab if T ≥ 37.8 °C
every 4 h

Priority 2: Acute pain related to disease process as evidenced by lymphadenopathy and swelling at the right submandibular area with a verbal report of pain
(7/10), intermittent pain at the sternal area with a pain scale of (9/10), dysphagia

Assessment Planning Intervention Rationale Evaluation

SUBJECTIVE:
>“Sobrang sakit ng dibdib
at dito sa gilid ng mukha
ko.” (Client points at her
right submandibular area)
>Pain scale of 7/10 and
9/10
OBJECTIVE:
>guarding position
> weak appearance
> presence of
After performing the
nursing interventions, client
will:
>Verbalize relief of pain
>Cite the relaxation
techniques taught
> Perform deep breathing
exercises so that pain will
>Assess pain, noting
location, characteristics,
intensity (0-10 scale).
> Encourage patient
to verbalize concerns.
Actively listen to these
concerns and provide
support by acceptance,
remaining with patient and
giving appropriate
> Helps evaluate degree of
discomfort and may reveal
developing complications.
> Reduction of
anxiety or fear
that can promote
relaxation and comfort.
After performing the
nursing interventions,
client:
>Verbalizes slight relief of
pain but still it was present
with a rate of 7/10
>Cited the relaxation
techniques correctly
 lymphadenopathy at the be reduced. information. > Client also performed
right submandibular area deep breathing exercises in
>intermittent pain on the > Provide comfort measure > Reduces muscle reducing discomfort.
sterna area like back rub or deep tension,
>dysphagia breathing exercises. promotes
>dysphasia – due to relaxation, and
lymphadenopathy / tonsillar may enhance
abscess coping abilities.
> Vital Signs taken as
follows: >Encourage socialization >These are used to divert
T: 36°C with others, listen to the client’s attention on the
PR: 98 radio or read some pain
RR: 22 magazines and
BP: 110/70 newspapers if the client
wanted to.

> Provide rest periods to > Pain may result in

facilitate comfort, sleep, fatigue, which may result in
and relaxation. The exaggerated pain and
patient’s experiences of exhaustion. A quiet
pain may become environment, a darkened
exaggerated as the result room, and a disconnected
of fatigue. phone are all measures
geared toward facilitating
rest.

COLLABORATIVE:
>Administer > Relieves pain, enhances
medications as comfort and promotes rest.
indicated:
Drug: Tramadol
Drug dosage: 50 mg
Route: I.V.
Frequency: q. 8 h

Priority 3: Risk for infection related to immunosuppression and presence of IV catheter.

Assessment Planning Intervention Rationale Evaluation

OBJECTIVE: After performing the > Inspect skin describing > Monitor wound healing After performing the
> Vital Signs taken as nursing interventions, client wound characteristics and
follows: will: any changes being
T: 36°C observed.
PR: 98 >Verbalize understanding
RR: 22 of risk factors > Prevent infection through
BP: 110/70 proper wound cleaning
> Lab result: Low RBC, > Develop no signs of
Low WBC inflammation, infiltration
> Presence of a IV catheter and infection on IV site > Discuss the importance
at the dorsum of the left of early detection of skin
hand. changes
> Teach client and
significant other about
wound care and inspection
of wound drainage
> Discuss patient’s diet
with increased intake of
Vitamins A, C, D, & E and
protein once client is
allowed
>Observe good oral
hygiene.
>As much as possible,
minimize puncturing of
needle into client’s skin
>Always wear a mask
progress nursing interventions,
client:
>Verbalized understanding
> A contaminated wound is of risk factors
more likely to become
infected. > Developed no visible
signs of inflammation,
> Prevent further infiltration and infection on
complications IV site until the end of the
shift
> Prevent any
complications
> Aids in wound healing by
providing positive nitrogen
balance. Protein is for
rebuilding of cells and Vit.
A & C are for re-
epithelialization.
>Gargle with mouthwash to
prevent bacteria from
multiplying so as to prevent
further infection.
>Since client is on
immunosuppressant
medication, lesser trauma
to the skin is encouraged
due to inhibition of
immunocompetent T
lymphocytes.
>Client on
immunosuppressive
medication and is admitted
in a ward increasing the
chance of harboring
infection from other
patients.
 PRIORITY #1: Acute Pain/Discomfort related to respiratory distress as evidenced by complaints of discomfort
ASSESSMENT
Subjective:
>Client verbalized, "Hirap na
hirap na akong huminga at
ang sikip-sikip ng dibdib ko.
Tulungan mo ako."
>"Ang hirap at masakit sa
dibdib habang hinahabol ko
ang aking paghinga."
>Pain scale 4/10
Objective:
>Shallow breathing through
his mouth
>Nasal flaring
>Facial grimacing
>Respiratory depth changes
>Weakness in appearance
>Vital signs
T:36.3
PR:110
RR:33
BP:170/90
PLANNING
Short term goal:
At the end of this shift, the
client will:
>Patient verbalizes relief or
reduction in pain from 4/10 to
2/10.
>Patient appears relaxed and
comfortable.
>Patient verbalizes the
understanding of non-
pharmacological interventions
for pain relief.
INTERVENTION
1) Assess complaints of
discomfort: pain or discomfort
with breathing, shortness of
breath, muscle pains, pain with
coughing.
2) Monitor for non-verbal
signs of discomfort like
grimacing, irritability,
tachycardia, increased BP.
3.) Elicit how the patient has
effectively dealt with pain in
the past.
4) Administer appropriate
medication
5) Administer analgesic as
prescribed and as needed.
6) Use additional measures,
including positioning and
relaxation techniques like deep
breathing exercices, pursed lip
breathing as indicated.
RATIONALE
1) Pain can result in shallow
breathing and poor cough
effort.
2) Specific manifestations
guide interventions.
3) This provides opportunity to
consider the patient's reactions
to and expectations for pain
relief.
4) Careful balancing of dosage
is needed to prevent reduction
in respirations seen with some
analgesics.
5) Medications allow for pain
relief and the ability to deep
breath and cough. Analgesic
prevent peak periods of pain
6) These facilitates effective
respiratory excursion
EVALUATION
After doing the necessary
nursing health teachings,
the client has:
>Clients appreciates the
effectiveness of the
interventions
>Verbalized awareness of
factors that causes her
breathing problems and able
to use means to reduce the
pain
>Able to demonstrate back
the non-pharmacologic
therapy for pain relief and
understood the rationale of
having to do them.
.
 7) Auscultate the lungs after 7) This helps to evaluate the
the interventions. effectiveness of the
interventions done.

PRIORITY #2: Ineffective Breathing Pattern related to alteration of the normal oxygen saturation as evidenced by
recurrence of DOB upon exertion

ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Short-term goal Independent
After doing the necessary
>Client verbalized, At the end of this shift, the 1) Inspected the throat, 1) To determine the cause of nursing interventions and
“Paminsan-minsan client will: describing the color, presence breathing problems This will teachings, the client:
nahihirapan ako huminga, of exudates, or swelling. provide a data that could be
minsan nawawala tapos used to evaluate the proper
bumabalik din kapag pagod >Be able to verbalize factors intervention that the client >Verbalized awareness of
ako.” that causes her dyspnea. needs. factors that causes his
breathing problems
“Pagkatapos ko maglakad ng 2) Encouraged the client to 2) To help in expectorating the
mahaba madalas nahihirapan increase the fluid intake. mucus secretions.
na ko huminga.”
3) Identified factors that causes 3) This varies with each >Verbalized understanding
>Easy fatigability >Verbalize lifestyle changes his breathing impairment individual and situation. of the given information.
that she will do to avoid
Objective recurrence of dyspnea. 4)Auscultate his chest 4) To evaluate the character of
>Vital signs breath sounds
T:36.3 >Verbalized that he will
PR:110 5) Reviewed the results of his 5) To assess the cause of adhere to the prescribed
RR:33 beats/min laboratory testing like chest dyspnea and other respiratory pharmacological regimen.
BP:170/90 x-ray,02 saturation, and problems
>Understand the health hematology.
>Shallow breathing through teachings >Demonstrated use of
his mouth 6) Evaluate his cough and 6) Secretions obstruct airways relaxation skills.
>Nasal flaring presence of secretions which causes breathing
>Facial grimacing impairments.
>Respiratory depth changes
>Weakness in appearance 7)Provided health teachings >Responded to the health
such as: teaching
-using of pursed-lip breathing >To assist the client in

>Verbalize appropriate coping
behaviors
technique
-activity modification
8) Encouraged the client to
limit activities and avoid
smokers, exposure to dust,
perfumes, animals, etc.
9) Facilitated the use of
nebulizer
controlling dyspnea.
>Verbalized appropriate
>to reduce fatigue coping behaviors and
lifestyle changes that she will
do.
8)To limit fatigue that will
cause dyspnea and SOB
9) To lessen respiratory
distress
 PRIORITY #3: Readiness for enhanced knowledge as evidenced by verbalization of interest in health teachings regarding
diet/activity modification
ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Short term goal:
After doing the necessary
>Verbalization of questions: At the end of this shift, the nursing health teachings,
“Ano ba ang mga dapat kong client will: 1) Asked client of what’s his 1) To identify best approaches the client has:
iwasan pag labas ko dito? preferred methods of learning. to facilitate learning progress.

>Expresses interest in >Verbalize that he will use >Responded to the learning

learning given information in all 2) Encouraged client to explore 2) To promote ongoing plan and actions performed.
applicable areas including on additional learning learning at his own pace.
>Verbalized previous environmental and personal. resources like internet and
experiences regarding his other medical books and >Provided a positive
disease. references. feedback with the instructor.

>Easy fatigability >Verbalize understanding of 3)Teach client the following:

the provided information.
nd
Objective: -Avoid smoking, 2 hand
smoking and ingestion of
>Patient for discharge alcohol
>Verbalized understanding
-Avoids recurrence of of the given info.
symptoms

>Alert and coherent >Use the information gained to -Have adequate rest -Prevents fatigue
meet her health care goals
>Ambulatory -Avoid excessive activity -Prevents dyspnea

>Vital signs -Maintain proper cholesterol -To control CAD

T:37.7 levels through dietary
PR:94 reduction of cholesterol intake
RR:26 and meds management and
BP:140/90 maintenance.