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NURSING CARE PLAN

NURSING PROBLEM #1
Subjective:
Nakukurihan ak magginhawa. as verbalized.

Assessment

Nursing Diagnosis

Scientific Rationale

Objective:
Restlessness
Tachypnea at 28cpm
Tachycardia at 107bpm
Pallor noted
Capillary refill: 4sec
O2 Sat. at 87-88%
Impaired Gas Exchange related to altered oxygen supply
(obstruction of airways by secretion) as evidenced by restlessness
and tachypnea at 28cpm
Entry of noxious particles or gases to the lungs

Release of mediators

Abnormal inflammation of the lungs

Chronic inflammation

Scar tissue formation

Narrowing of airway lumen

Airflow limitations

Impaired gas exchange

Restlessness
Tachypnea at 28cpm
Tachycardia at 107bpm
Pallor noted
Capillary refill: 4sec
O2 Sat. at 87-88%
Reference: Pathophysiology by Gold, 4th edition p.345

Long-Term Goal: After 3 days of nursing intervention the client


will:
-Manifest absence of adventitious breath sounds upon
auscultation
-Attain normal breathing pattern of 20cpm
Objectives/Planning

Nursing Interventions
and
Scientific Rationale

Short-Term Goal: After 8 hours of nursing intervention the


client will:
-Demonstrate improved ventilation and adequate oxygenation of
tissues
-Decrease respiratory rate from 28cpm to 18cpm
-O2 saturation at 95-100%
Nursing Interventions
Scientific Rationale
Independent:
-Monitor skin and mucous
-Duskiness and central cyanosis
membrane color
indicate advanced hypoxemia
-Elevate head of the bed, assist -Oxygen delivery may be
patient to assume position to
improved by upright suctioning
ease work of breathing
-Suction when needed
-Suctioning is required when
cough is ineffective for
expectoration of secretions
-Auscultate breath sounds,
-Presence of wheezes may
noting areas of decreased airindicate bronchospasm/
flow or presence of
retained secretions
adventitious sound
-Palpate for fremitus
-Decrease of vibratory tremors
suggest fluid collection or air
tapping
-Provide quiet environment to
-External stimuli may prevent
allow the patient to relax
relaxation or inhibit sleep
Collaborative:
-Monitor pulse oximetry and
ABGs
-Administer antianxiety,
sedative, or narcotic agents as
indicated

-to identify if hypoxia is present


-to reduce dyspnea by
controlling the anxiety and
restlessness
Reference:
Nursing care Plan by Marilyn
Doenges, 7th edition p.124-125

Evaluation

Long-Term Goal: ACHEIVED


After 3 days of nursing intervention the client:
-Manifested absence of adventitious breath sounds upon
auscultation

-Attained normal breathing pattern of 20 cpm


Short-Term Goal: ACHIEVED
After 8 hours of nursing intervention the client:
-Demonstrated improved ventilation and adequate oxygenation of
tissues
-Decreased respiratory rate from 28cpm to 18cpm
-O2 saturation within 95-100%

NURSING PROBLEM #2
Subjective:
Masuol ak dughan, ak likod, pati ak tiyan! as verbalized.
PRS = 8
Assessment

Nursing Diagnosis

Objective:
Facial grimace
Restlessness
Guarding behavior
Frequent position changes
Acute Pain related to tumor effects, invasion of adjacent
structures, toxicities associated with medication therapy

Mechanical, thermal or chemical stimuli.


Nociceptors
Afferent Nerves
End terminals
unmyelinated C fibers and myelinated-A delta fibers
Scientific Rationale
spinal cord
brain cortex
Pain
Reference: Maternal and Child Health Nursing 5th e. by Pilliteri
page 545

Long-Term Goal:
After 5 days of nursing interventions, the client will be free from
experiencing pain.
Objectives/Planning

Nursing Interventions
and
Scientific Rationale

Short-Term Goal:
After 8 hours of nursing interventions the client will:
-state 3 ways of relieving pain such as imagery, application of hot
and cold compress and therapeutic touch.
-report decrease of pain scale from 8/10 to 5/5.
Nursing Interventions
Scientific Rationale
Independent:
-Encourage patient to verbalize -Promotes cooperation from the
about pain.
client. (Fundamentals of
Nursing by Taylor 5th e.
p.1216)
-Provide comfort measures
-This calms and soothes the
such as deep breathing
patient. (Fundamentals of
exercises
Nursing by Taylor 5th e.
p.1216)
-Encourage divertional
-To divert attention from pain.
activities (TV/radio,
(Fundamentals of Nursing by
socialization with others,
Taylor 5th e. p.1216)
imagery)
-Provide application of hot and -To relieve pain in the muscle
cold compress.
area. Maternal and Child Health
Nursing 5th e. by Pilliteri page
547)
-Provide therapeutic touch.
-To promote feeling of comfort.
(Maternal and Child Health
Nursing 5th e. by Pilliteri page
547)
-Monitor Vital signs.
-An information baseline
comparison from previous data.
(Manual of Nursing Procedures
Vol. I by Locquiao, Cruz,
Arguelles and Lontoc page 122)
-Position patient on moderate
-To promote comfort and
high back rest or in
maximum lung expansion
comfortable position
Collaborative:
-Administer analgesics as
ordered.

-To comply with the


physicians order. (Manual of
Nursing Procedures Vol. II
Locquiao, Manalastas, Mejilla
and Merin. page 3)

Long-Term Goal: ACHEIVED


After 5 days of nursing interventions, the client verbalized
absence of pain.
Evaluation
Short-Term Goal: ACHEIVED
After 8 hours of nursing interventions the client:
-stated 3 ways of relieving pain such as imagery, application of
hot and cold compress and therapeutic touch.
-reported decrease of pain scale from 8/10 to 5/5.

NURSING PROBLEM #3
Subjective:
Ginhahapo ak tas gin-inubo liwat! as verbalized.

Assessment

Nursing Diagnosis

Scientific Rationale

Objectives/Planning

Objective:
Increase in respiratory rate of 28cpm
Shortness of breath (orthopnea)
Dyspnea
Use of accessory muscles in breathing
Altered chest excursion
Nasal flaring
Increased anterior-posterior diameter
Ineffective Breathing Pattern related to presence of secretions
AEB productive cough and dyspnea associated with lung cancer
Presence of secretions in the bronchi will result into a blockage of
air that will enter the body and thus producing insufficient air
needed by the body. And inability to maintain clear airway. This
obstruction is further heightened by bronchospasm due to the
contraction of the smooth muscles in the bronchi. This is caused
by parasympathetic stimulation of the muscarinic2 receptors as
well as by chemical mediators released.
Reference: http://www1.us.elsevierhealth.com/SIMON/Ulrich/
Constructor/diagnoses.cfm?did=31
Long-Term Goal:
After 2-3 days of nursing intervention, patient will establish
normal breathing pattern.
Short-Term Goal:
After 8 hours of nursing intervention, patient will be able to

Nursing Interventions
and
Scientific Rationale

verbalize understanding and demonstrate proper deep breathing


technique to facilitate proper oxygenation to alleviate
hyperventilation.
Nursing Interventions
Scientific Rationale
-Establish rapport with patient -To gain patients trust and
cooperation
-Instruct patient to increase
-Increased mucus and sputum
oral fluid intake to 8-10
secretions can lead to
glasses
dehydration; increased water
intake can help dissolve
secretions
-Instruct patient to do deep
-Deep breathing exercise
breathing exercise after
increases oxygen intake and can
demonstrating proper
help alleviate dyspnea
technique
-Keep environment allergen
-Presence may trigger allergic
free (dust, feather pillows,
response that may cause further
smoke, pollen)
increase in mucus secretion
-Take and VS
-To get baseline data
-Suction naso, tracheal/oral
-These may compromise airway.
PRN
A distended abdomen can
interfere with normal diaphragm
expansion
-Educate proper hand washing -To increase feeling of comfort
-Position the patient in semi
-To enable the body to recuperate
fowlers position
and repair
-Encourage patient to eat
-To prevent infections such as
nutritious foods such as green nosocomial infections
leafy vegetables and lean
meat
-Review clients chest x-ray
-To prevent allergic reactions
for severity of acute/ chronic
that can cause respiratory distress
conditions
Reference:
http://nursinglibrary.info/nursingcare-plan-for-ineffectivebreathing-pattern/
Long-Term Goal: ACHEIVED
After 2-3 days of nursing intervention, patient established a
normal breathing pattern.

Evaluation
Short-Term Goal: ACHEIVED
After 8 hours of nursing intervention, patient verbalized
understanding and demonstrated proper deep breathing technique
to facilitate proper oxygenation to alleviate hyperventilation.

NURSING PROBLEM #4

Subjective:
Di ko kam ma-entertain kay nanluluya ak!as verbalized.

Assessment

Nursing Diagnosis

Objective:
Weak in appearance.
Cannot perform ADLs alone.
With limited range of motion.
Muscle strength:
Left upper extremity=5; Right upper extremity=5;
Left lower extremity=4; Right lower extremity=2

Activity Intolerance related to decreased energy requirements as


evidenced by decrease muscle strength.

Muscle weakness ---> Chest pain, back pain, abdominal pain --->
reduction of muscle strength ---> impaired ability to maintain
Scientific Rationale

activity ---> inability to begin or perform activity --->


Activity Intolerance
Reference: http://ncplist.blogspot.com/2012/06/activityintolerance-nursing-diagnosis.html

Objectives/Planning

Long-Term Goal:
After 5 days of effective nursing interventions, the patient will be
able to maintain activity level within capabilities as evidenced by
normal vital signs during activity, as well as absence of weakness,
pain, and difficulty accomplishing tasks.
Short-Term Goal:
After 8 hours of effective nursing interventions, the patient will
be able to do ADLs alone and to participate in self-care
activities.

Nursing Interventions
> Monitor vital signs and
record.

> Monitor intake and


as order.

Nursing Interventions
and
Scientific Rationale

output

> Assess ability to perform


ADL.
> Assess physical mobility
status.
> Assist patient to do ADLs.

> Assist to do active range of


motion exercise like flexing of
both extremities.
> Promote rest and comfort.
> Encourage to verbalize
feelings and concern regarding
his present condition.
> Emphasize importance of
frequent ambulation.
> Encourage active range of
motion exercises like flexing of
both extremities.
> Emphasize importance of
compliance to treatment and
medication.
> Encourage adequate rest
periods.

Scientific Rationale
> To help determine patients
current health status and
evaluate effectiveness of
nursing intervention rendered.
> To evaluate the proper
functioning of his kidney in
relation to his present condition.
> To determine the capacity of
patient in doing ADLs.
> To know if there is any
changes on patients condition
specifically on physical aspect.
> To minimize fatigue and to
evaluate his capabilities in
doing such.
> To maximize full strength.

> To conserve energy.


> To determine other factors
that might contribute to
patients present condition.
> To promote circulation and.
> To maximize full strength.

> To achieve therapeutic effect


of medication and for fast
recovery.
> Rest between activities
provides time for energy
conservation.
Reference:
http://nurseslabs.com/activityintolerance-nursing-diagnosis/

Evaluation

Long-Term Goal: PARTIALLY MET


After 5 days of effective nursing interventions, the patient was
able to partially maintain activity level within capabilities as
evidenced by normal vital signs during activity, as well as
absence of weakness, pain, and difficulty accomplishing tasks.

Short-Term Goal: PARTIALLY MET


After 8 hours of effective nursing interventions, the patient was
able to partially do ADLs alone and to participate in self-care
activities.

NURSING PROBLEM #5

Assessment

Subjective:
Wara ak gana kumaon. Ditoy la ak nakakaon. as verbalized.
24 hours dietary recall
Breakfast: 1 slice of bread and coffee
Lunch: Egg, rice, 1 spoon vegetable
Dinner: Rice and 1 pc of fish
Objective:
Small body frame
Weak in appearance
Pale conjunctiva and mucous membrane
Dry skin
Loss of appetite
Muscle wasting

Nursing Diagnosis

Imbalanced Nutrition: Less Than Body Requirements related


to hypermetabolic state, taste aversion, anorexia secondary to
medication therapy
Unfamiliar or unpalatable food Decreased strength and stamina
Decreased food intake Intake insufficient to meet metabolic
needs Imbalance nutrition less than body requirement.

Scientific Rationale

Reference: http://nurseslabs.com/tag/imbalanced-nutrition-lessthan-body-requirements/

Long-Term Goal:
After 1 week of nursing intervention the client will demonstrate
progressive weight gain toward goal.
Objectives/Planning

After 1 week of nursing intervention the client will demonstrate


behaviors, lifestyle changes to regain/maintain weight.
Short-Term Goal:
After 8hrs of nursing intervention the client family will be able
to verbalize understanding of causative factors when known
and necessary interventions.
Nursing Interventions
1.Demonstrate clients ability
to chew, swallow and taste
food.

Scientific Rationale
1. All factors that can affect
ingestion and digestion of
nutrients.

2.Ascertain understanding of 2. To determine informational


individual nutritional needs. need of the client.

Nursing Interventions
and
Scientific Rationale

3.Evaluate impact of cultural,


ethnic, or religious desires/
influences.

3. That may affect food choices.

4.Prevent /minimize
unpleasant odors.

4. May have negative effect in


the appetite.

5.Encourage to buy the


5. To provide nutritional support.
prescribe medicine given by
the physician
Reference:
http://nursinginterventions
rationales.blogspot.com/2013/07/
imbalanced-nutrition-more-thanbody.html

Evaluation

Long-Term Goal: UNMET


After 1 week of nursing intervention the client did not
demonstrate progressive weight gain toward goal.
After 1 week of nursing intervention the client did not
demonstrate behaviors, lifestyle changes to regain/maintain
weight.
Short-Term Goal: ACHEIVED
After 8hrs of nursing intervention the client family was able to
verbalize understanding of causative factors when known and
necessary interventions.