CHINESE GENERAL HOSPITAL COLLEGE OF NURSING AND LIBERAL ARTS

NURSING CARE PLAN

NAME: Wesley Arizapa AGE: 4 months CATEGORY: Abandoned

ASSESSMENT NURSING DIAGNOSIS INFERENCE GOALS INTERVENTION RATIONALE EVALUATION

SUBJECTIVE Ineffective airway Irritant Short Term Goal: INDEPENDENT Short Term Goal:
As Auntie clearance related to ↓ After 5 hours of  Monitor respirations  Indicative of After 5 hours of nursing
verbalized, retained secretions Inflammation of the nursing intervention, the and breath sounds, respiratory distress intervention, the patient’s
“May ubo at airway patient will be able to noting rate and and accumulation of goal are partially met, as
sipon siya. ↓ reduce congestion, as sounds. secretions. manifested by:
Nahihirapan Increased secretion manifested by:  Position head  To open or maintain  RR = 70 cpm
siyang ilabas production  Sustain respiratory appropriate for age/ open airway in at-rest  Relaxed
secretions, kaya ↓ rate within normal condition. or compromised  Expelled secretions
nagnenebulize Constriction of the range of 30-60 cpm individual.
siya.” airway  Allay restlessness  Monitor infant for  To maintain adequate
↓  Expulsion of feeding intolerance, and patent airway.
OBJECTIVE Difficulty of secretions abdominal distention,
 Restlessness breathing and emotional
 (+) cough stressors.
 RR = 88 cpm
 (+) wheeze
DEPENDENT  To mobilize
 Give expectorants/ secretions.
bronchodilators as
ordered.  Nebulization can
 Provide supplemental liquefy viscous
humidification via use secretions and
of nebulizer improve secretion
clearance.

Name of Student: Lucero, Anna Patricia G. Year and Section/ Group: 3B/ Group 3
 CHINESE GENERAL HOSPITAL COLLEGE OF NURSING AND LIBERAL ARTS
NURSING CARE PLAN

NAME: Wesley Arizapa AGE: 4 months CATEGORY: Abandoned

ASSESSMENT NURSING INFERENCE GOALS INTERVENTION RATIONALE EVALUATION

DIAGNOSIS

SUBJECTIVE Hyperthermia Exogenous pyrogens Short Term Goal: INDEPENDENT Short Term Goal:
As Auntie related to ↓ After 5 hours of  Identify the  To assess causative After 5 hours of
verbalized, Dehydration Monocytes, macrophages, nursing intervention underlying cause. factors. nursing intervention the
“Nilalagnat na endothelial cell, other the patient will be able  Monitor heart rate  Dysrhytmias and patient’s goals are
ngayon si immune cells to maintain core ECG changes are partially met as
and rhythm.
Wesley, ↓ temperature within common due to manifested by:
nagtatae pa Anterior hypothalamus normal range, as electrolyte  T= 37.8 o C
siya. ↓ manifested by: imbalance,  Skin warm to touch
Elevated  Reduced dehydration, specific  Restlessness
OBJECTIVE thermoregulatory set- temperature action of
 Flushed skin point  Relax catecholamines, and
 V/S are as ↓  Absence of flush direct effects of
follows: Heat conservation skin hyperthermia on
T = 38.3 o C (vasoconstriction,behavior blood and cardiac
CR =140 changes) and Heat tissue.
bpm production (involuntary
 Record all sources of
RR = 49 cpm muscle contractions)  To evaluate degree
fluid loss.
 Constant ↓ of hyperthermia.
crying Fever  Note presence/
absence of sweating  Evaporation is
as body attempts to decreased by
increase heat loss by environmental
evaporation, factors of high
conduction and humidity and high
ambient
diffusion.
temperature, as well
as body factors
 producing loss of
ability to sweat or
sweat gland
dysfunction.
DEPENDENT
 Administer
antipyretics orally, as  To assist with
ordered. measures to reduce
temperature.

Name of Student: Lucero, Anna Patricia G. Year and Section/ Group: 3B/ Group 3