NURSING CARE PLAN

Name of the Patient: Mr. M. D.
Diagnosis: ------
ASSESSMENT DIAGNOSIS RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION
S: “Meron syang ubo’t
sipon, ilang araw na.”
As verbalized by th
mother of the patient.

O:
 Productive
cough
 Colds with
clear
secretions
 Nasal Flaring
 RR: 8 AM: 27
cpm
12 AM: 25 cpm
Ineffective
Airway
Clearance
Irritant
(Inhalation)


Inflammatory
Response


Increase
Production of
secretions


Airway
constriction


Dyspnea

Ineffective Airway
Clearance Inability
to clear secretions
or obstructions
from the
respiratory
tract to maintain
a clear airway.

After 8 hours of
nursing
intervention,
airway
clearance
patency will be
maintained,
secretions will
be readily
expectorated
and there will
be signs of
reduction in
congestion.
 Vital signs taken
and recorded.


 Assisted in Semi-
fowler’s position.


 Encouraged
breathing
exercises.

 Administered
prescribed
medications.



 Provided
supplemental
humidification
via use of
nebulizer.
This is for
baseline
comparison.

Proper
positioning help
in draining
secretions.
This will
promote proper
lung expansion.

Prescribed meds
such as
bronchodilators
helps in aiding
effective airway
clearance.
Nebulization
helps in
liquefying
secretion for
better and faster
expectorating
the secretions.

After 8 hours
of nursing the
patient will
maintain
airway patency
and reduction
of congestion.
NURSING CARE PLAN
Name of the Patient: Mr. R. J. C
Diagnosis: DFS
ASSESSMENT DIAGNOSIS RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION
S: “Pwede na
dapat sya
umuwi, kaso
tuaas naman an
bp nya.” As
verbalized by
themother of
the patient.

O:
Altered Blood
Pressure
(Increase)
8:00 am: 140/80
9:00 am: 110/70
12:00 nn:
130/80
Ineffective
Peripheral Tissue
Perfusion related
to
vasoconstriction
of blood vessels.
Increased cardiac
output that
injures the
endothelial cells
of the arteries
and the action of
prostaglandins.
Vasoconstriction
occurs and blood
pressure
increases.
After 8 hours of
nursing
intervention the
patient blood
pressure will
decrease from
140/80 to
120/70 mmHg.
 Monitored blood
pressure.


 Instructed to
have enough
rest.

 Instructed to eat
low fat and low
salt diet.




 Administered
anti -
hypertensive
drug as ordered.


This is for
baseline
comparison.

Sodium tends to
be excreted at a
faster rate.

To prevent
edema that may
activate renin
angiotensin –
aldosterone
system.

To control BP
and to avoid
other
complications.

After 8 hours of
nursing
intervention the
patient’s blood
pressure was
decreased from
140/80 to
120/70 mmHg.




NURSING CARE PLAN
Name of the Patient: Mr. N. B. M
Diagnosis: DHF
ASSESSMENT DIAGNOSIS RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION



























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