Patient: GANDOL, Jose Attending Physician: Dr. Sta.

Maria
Age: 72 Sex: M CS: Married
Address: Sta. Lucia, Ilocos Sur
Case: COPD with Concomitant Pneumonia

NURSING CARE PLAN

SCIENTIFIC
NURSING NURSING NURSING
ASSESSMENT BACGROUND/INFERENC RATIONALE EVALUATION
DIAGNOSIS OBJECTIVE INTERVENTION
E
SUBJECTIVE: Ineffective airway Ineffective Airway Date: October 9, Auscultate breath Some degree Date: October 9,
Haan nak clearance related Clearance: Inability to clear 2017, 2017 sounds. Note of bronchospasm is 2017, 2017
makaanges nukwa to increased secretions or obstructions Time: 7:30 adventitious breath present with Time: 11:30
maam, lalo no production of from the respiratory tract to Shift: 7:00 4:00 sounds (wheezes, obstructions in Shift: 7:00 4:00
ikkaten da detoy secretions as maintain a clear airway. crackles, rhonchi). airway. After 4 hours of
oxygen ko evidence by After 4 hours Assess and monitor Tachypnea is intervention the
maam, as verbalization of of nursing respirations and usually present to patient can
verbalized by the Difficulty of intervention breathe sounds, some degree and demonstrate
patient. breathing. noting rate and may be pronounced behaviors to
patient will
sounds (tachypnea, on admission or improve airway
OBJECTIVE: demonstrate clearance. GOAL
stridor, crackles, during stress or
Vital Signs taken behaviors to and wheezes). Note concurrent acute MET.
as follows: improve airway inspiratory and infectious process.
T: 36.0 clearance, e.g., expiratory ratio.
PR: 107 bpm cough effectively Assist patient to Elevation of
RR: 20 cpm and expectorate assume position of the head of the bed
BP: 120/80 comfort (elevate facilitates
secretions.
mmHg head of bed, have respiratory function
patient lean on over by use of gravity;
bed table or sit on however, patient in
edge of bed). severe distress will
seek the position
Keep that most eases
environmental breathing.
pollution to a Precipitators
minimum such of allergic type of
as dust, smoke, and respiratory
feather pillows, reactions that can
 according to trigger or
individual exacerbate onset of
situation. acute episode.
Demonstrate chest
physiotherapy, such
as bronchial These
tapping when in techniques will
cough, proper prevent possible
postural drainage. aspirations and
prevent any
untoward
complications
 SCIENTIFIC
NURSING NURSING NURSING
ASSESSMENT BACGROUND/INFERENC RATIONALE EVALUATION
DIAGNOSIS OBJECTIVE INTERVENTION
E
SUBJECTIVE: Imbalance Unpleasant sensory and Date: October 9, Ascertain To determine Date: October 9,
Haan nak nutrition: Less emotional experience 2017, 2017 understanding of informational 2017, 2017
makapanagan than Body arising from actual or Time: 7:30 individual needs of client and Time: 11:30
maam ta nasakit Requirements potential tissue damage or Shift: 7:00 4:00 nutritional needs. SO. Shift: 7:00 4:00
nukwa nga described in terms such After 4 hours of After 4 hours of
tilmunen, as damage (International nursing Assess dietary Patient in acute intervention the
verbalized by the Association for the Study of intervention habits, recent food respiratory distress patient can
patient. Pain); Sudden or slow onset patient will be intake. Note degree is often anorectic verbalized and
of any intensity from mild relieved and he of difficulty with because of demonstrate relief
OBJECTIVE: to severe with an anticipated will know how to eating. Evaluate dyspnea, sputum and control pain.
Vital Signs taken or predictable end. relieve his pain. weight and body production, and
as follows: His pain scale will size (mass). medications.
T: 36.0 decreased into 1 Noxious tastes,
PR: 107 bpm out 10. Give frequent oral smells, and sights
RR: 20 cpm care, remove are prime
BP: 120/80 expectorated deterrents to
mmHg secretions appetite and can
promptly, provide produce nausea and
specific container vomiting with
for disposal of increased
secretions and respiratory
tissues. difficulty.
Helps
reduce fatigue durin
g mealtime, and
Encourage a rest
provides
period of 1 hr
opportunity to
before and after
increase total
meals. Provide
caloric intake.
frequent small
feedings. Decreases dyspnea
and increases
energy for eating,
Administer enhancing intake.
supplemental
oxygen during
meals as indicated.
 SCIENTIFIC
NURSING NURSING NURSING
ASSESSMENT BACGROUND/INFERENC RATIONALE EVALUATION
DIAGNOSIS OBJECTIVE INTERVENTION
E
OBJECTIVE: Risk for infection Risk for Infection: At
Date: October 9, Monitor temperature. Fever may be Date: October 9,
Vital Signs taken 2017, 2017 present because 2017, 2017
as follows: increased risk for being Time: 7:30 of infection Time: 11:30
T: 36.0 invaded by pathogenic Shift: 7:00 4:00 or dehydration Shift: 7:00 4:00
PR: 107 bpm Review importance of These activities After 4 hours of
RR: 20 cpm organisms. intervention the
After 4 hours of breathing exercises, promote
BP: 120/80 effective cough, mobilization and patient can
mmHg nursing expectoration of verbalized and
frequent position
intervention changes, and adequate secretions to demonstrate
fluid intake. reduce risk of relief and control
patient will able pain.
developing
to verbalize pulmonary
understanding of infection.
Prevents spread
individual of fluid-borne
Demonstrate and assist
causative/risk pathogens.
patient in disposal of
factors. tissues and
sputum. Stress proper h
Reduces oxygen
and washing (nurse and
consumption or
patient), and use gloves
demand
when handling or
imbalance, and
disposing of tissues,
improves
sputum containers.
patients
resistance to
Encourage balance infection,
between activity and promoting
rest. healing.

Patient: BAGORIO, Clemente Attending Physician: Dr. Sunio

Age: 67 Sex: M CS: Married
Address: Namalangan, Santa, Ilocos Sur
Case: Hypertension Stage II

NURSING CARE PLAN

NURSING SCIENTIFIC NURSING NURSING

ASSESSMENT RATIONALE EVALUATION
DIAGNOSIS BACGROUND/INFERENCE OBJECTIVE INTERVENTION
SUBJECTIVE: Risk for Decreased Cardiac Date: October 9, Review clients at Persons with acute or Date: October 9,
Maulaw nak decreased Output: Inadequate blood pum 2017 risk as noted in chronic conditions may 2017
maam, as cardiac output ped by the heart to meet Time: 7:30 Related Factors as compromise circulation Time: 11:30
verbalized by metabolic demands of the Shift: 7:00 4:00 well as individuals Shift: 7:00 4:00
and place excessive
the patient. body. After 4 hours of with conditions After 4 hours of
nursing that stress the demands on the heart. intervention the
OBJECTIVE: intervention heart. patient can
Vital Signs patient will able participate in
taken as to participate in Monitor and necessary and
follows: activities that record BP. Comparison of pressures desired
T: 36.0 reduce BP and Measure in both provides a more complete activities.
PR: 56 bpm cardiac arms and thighs GOAL MET.
picture of vascular
RR: 21 cpm workload. three times, 35
BP: 110/80 min apart while involvement or scope of
mmHg patient is at rest, problem.
then sitting, then
standing for initial
evaluation. Use
correct cuff size
and accurate
technique.
Maintain activity
restrictions
(bedrest or chair Lessens physical stress an
rest); schedule d tension that affect blood
periods of pressure and the course
uninterrupted rest; of hypertension.
assist patient with
self-care activities
as needed.
 Provide comfort
measures (back
and neck massage, Decreases discomfort and
elevation of head). may reduce sympathetic
Instruct in stimulation.
relaxation
techniques, guided Can reduce stressful
stimuli, produce calming
imagery,
effect, thereby reducing
distractions. BP.
Monitor response
to medications to Response to drug therapy
control blood (usually consisting of
pressure. several drugs,
including diuretics,
angiotensin-converting
enzyme [ACE] inhibitors,
vascular smooth muscle
relaxants, beta
and calcium channel
blockers) is dependent on
both the individual as well
as the synergistic effects
of the drugs.
 SCIENTIFIC
NURSING NURSING NURSING
ASSESSMENT BACGROUND/INFERENC RATIONALE EVALUATION
DIAGNOSIS OBJECTIVE INTERVENTION
E
SUBJECTIVE: Activity Insufficient physiologic or Date: October 9, Assess the clients Changes in baseline Date: October 9,
Agkakapsot nak intolerance related physiological energy to 2017 response to activity, are helpful in 2017
maam, as to generalized endure or complete required Time: 7:30 noting pulse rate assessing Time: 11:30
verbalized by the weakness as or desired activity. Shift: 7:00 4:00 more than 20 beats physiological Shift: 7:00 4:00
patient. evidence by cues After 4 hours of per minute faster responses to the After 4 hours of
presented nursing than resting rate; stress of activity intervention the
OBJECTIVE: intervention marked increase in and, if present, are patient can
Vital Signs taken patient will able to BP during and after indicators of participate in
as follows: participate in activity, dyspnea or overexertion. necessary and
T: 36.0 necessary and chest pain, desired activities.
PR: 56 bpm desired activities. excessive fatigue GOAL MET.
RR: 21 cpm and weakness, and
BP: 110/80 diaphoresis,
mmHg dizziness and
Facial grimace syncope.
Instruct client in Energy-saving
energy-conserving techniques reduce
techniques, such as energy expenditure,
using chair when thereby assisting in
showering, sitting equalization of
to brush teeth or oxygen supply and
comb hair, and demand.
carrying out
activities at a
slower pace.
Encourage Gradual activity
progressive activity progression
and self-care when prevents a sudden
tolerated. Provide increase in cardiac
assisitance if workload.
needed. Providing
assistance only as
 needed encourages
independence in
performing
Assess emotional activities.
and psychological Stress or depression
factors affecting may be increasing
the current the effects of an
situation. illness, or
depression might be
the result of being
forced into
inactivity.
 SCIENTIFIC
NURSING NURSING NURSING
ASSESSMENT BACGROUND/INFERENC RATIONALE EVALUATION
DIAGNOSIS OBJECTIVE INTERVENTION
E
SUBJECTIVE: Knowledge deficit Absence or deficiency of Date: October 9, Assess readiness and Misconceptions Date: October 9,
Maam normal regarding cognitive information 2017 blocks to learning. and denial of the 2017
ba detoy BPk?, condition related related to specific topic. Time: 7:30 Include significant diagnosis because Time: 11:30
as verbalized by to lack of Shift: 7:00 4:00 other (SO). of long-standing Shift: 7:00 4:00
the patient. knowledge as After 4 hours of feelings of well- After 4 hours of
evidence by the nursing being may intervention the
OBJECTIVE: cues presented. intervention interfere with patient can
Vital Signs taken patient will able patient and SO verbalize
as follows: to verbalize willingness to understanding of
T: 36.0 understanding of learn about disease process.
PR: 56 bpm disease process. disease, GOAL MET.
RR: 21 cpm progression, and
BP: 110/80 prognosis.
mmHg Define and state the Provides basis for
limits of desired BP. understanding
Explain hypertension elevations of BP,
and its effects on the and clarifies
heart, blood vessels, frequently used
kidneys, and brain. medical
terminology.
Understanding
that high BP can
exist without
symptoms is
central to enabling
patient to continue
treatment, even
when feeling well.
Avoid saying Because treatment
normal BP, and use for hypertension is
the term well- life long,
controlled to conveying the idea
describe patients BP of control helps
within desired limits. patient understand
the need for
 continued treatment
and medication.
Encourage patient to Besides helping to
establish an individual lower BP, aerobic
exercise program activity aids in
incorporating aerobic toning
exercise (walking, the cardiovascular
swimming) within system. Isometric
patients capabilities. exercise can
Stress the importance increase serum
of avoiding isometric catecholamine
activity. levels, further
elevating BP.