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ARELLANO UNIVERSITY

College of Nursing
S. Y. 2009 – 2010

NURSING CARE PLAN on


Community Acquired Pneumonia (CAP)

FEMALE WARD – JOSE REYES MEMORIAL MEDICAL CENTER


STA. CRUZ, MANILA, PHILIPPINES

SUBMITTED BY:

JUN CARY V. SUITOS, AUSN


GROUP – 64
III – MUSCARINICS

SUBMITTED TO:

_________________________________________
CLINICAL INSTRUCTOR

07 SEPTEMBER 2009
I. PERSONAL DATA

NAME : Patient ABC


AGE : 50 y/o
DATE OF BIRTH : May 8, 1959
GENDER : Female
ADDRESS : Recto, Manila
PRIMARY DIALECT SPOKEN: Tagalog
ETHNIC GROUP : None
RELIGION : Roman Catholic
OCCUPATION : Public Servant (Brgy. Secretary)
HIGHEST EDUC’L ATTAINMENT: High School
MARITAL STATUS : Separated

II. MEDICAL HISTORY

When she was a child, she have had experienced measles and chicken pox but was not medically diagnosed.
According to the patient, she doesn’t know if she was vaccinated of certain immunization at childhood due to her
parents died as early as she was 5 y/o. Also, according to her, she was admitted at the Jose Reyes Memorial Medical
Center due to complaint of cough, dyspnea, and chest pain.

III. PHYSICAL ASSESSMENT – VITAL SIGNS

SEPT. 1, 2009 (8:00 AM) SEPT. 1, 2009 (12:00 NN)


Pulse Rate : 80 bpm Pulse Rate : 100 bpm
Blood Pressure : 110/70 mmHg Blood Pressure : 110/80 mmHg
Respiratory Rate : 21 cpm Respiratory Rate : 34 cpm
Temperature : 36.5º C Temperature : 37.6 º C
IV. MEDICATION

Medications Frequency Time Remark


1. Levoflaxacin 500mg/ tab OD 8:00am; 2pm Not administered
2. Combinent Neb. q4h 8:00am; 12nn; 4pm; 8pm Done at 12:05 nn
3. FeSO4 + FA Tab TID 8:00am; 4pm Not administered
4. NaCl Tab TID 8:00am; 4pm Not administered

V. NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective: Independent:

“Masakit ang Acute pain r/t After four (4) hours • Elevate head Lowers diaphragm, After four (4) hours
dibdib ko”, as localized of nursing of the bed, promoting chest of nursing
verbalized by the inflammation and intervention, the change expansion and interventions, the
patient. persistent cough. patient will display position expectoration of patient was able to
patent airway with frequently. secretions. display patent of
Objective: breath sounds airway with breath
clearing and • Assist patient Deep breathing sounds clearing
• Use of absence of apnea with deep facilitates maximum and absence of
accessory breathing expansion of the dyspnea.
muscle exercises. lungs and smaller
• Dyspnea airways.
• Fatigue
• V/S taken • Demonstrate Coughing is a
as follows: of patient to natural self-
perform cleaning
(as of 9/1/09 – actively like mechanism.
8:00 am) splinting chest Splinting reduces
BP : 110/70 mmHg and effective chest discomfort,
PR : 80 BPM coughing and an upright
T : 36.5º C while in position favors
RR : 21 CPM upright deeper, more
position. forceful cough
(as of 9/1/09 – efforts.
12:00nn)
BP : 110/80 mmHg • Force fluids to Fluids especially
PR : 100 BPM at least warm liquids aid in
T : 37.6º C 3000ml / day mobilization and
RR : 34 CPM and offer expectoration of
warm, rather secretions.
than cold
fluids.

Collaborative:

• Administer Aids in reduction of


medications bronchospasm and
as prescribed mobilization of
by the secretions.
physician/s.

• Provide Fluids are required


supplemental to replace losses
fluids. and aid in
mobilization of
secretions.

Prepared by:

JUN CARY V. SUITOS, AUSN


Arellano University – 0900252
College of Nursing – Batch 2011
BSN III - Muscarinics