VII.

NURSING CARE PLAN
ASSESSMENT DATA (Subjective & Objective Cues) Subjective: NURSING DIAGNOSIS (Problem and Etiology) GOALS OBJECTIVES AND NURSING RATIONALE INTERVENTIONS AND EVALUATION

Ineffective airway Short term goal: INDEPENDENT: clearance related to After 15 minutes of ³ galisod siya ug storya tungod retained of secretions y Provided chest physiotherapy after thorough nursing nebulization. saiyang ubo ³ as verbalized by R: to remove the mucus intervention the patient the son secretions in the airways will be able to: Objective: Presence of crackles upon auscultation non-productive cough difficulty vocalizing Long term goal: After 2 days of thorough DEPENDENT: nursing interventions, y Nebulization (Combivent: 1 neb + the patient will achieve budesonide: ½ neb) done as totally effective airway ordered. clearance through R: to manage reversible complete expectoration bronchospasm associated w/ a. gradually expectorate retained secretions b. demonstrate various strategies to gradually achieve an effective airway. y Encouraged deep breathing and coughing exercises as indicated R: to strengthen respiratory muscles Encouraged and assisted with abdominal or pursed-lip breathing R: Provide patient with some means to cope with/control dyspnea and reduce air-trapping.

Short goal:

term

-

y

-

-

Goals met. After 15 minutes of thorough nursing intervention, the client was able to gradually expectorate retained secretions and demonstrated various strategies to gradually achieve an effective airway. Long goal: term

Goals met. After 2 days of thorough nursing

A case study on Prostatic Cancer with Bone Metastasis (Thorax) (thorax)

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VII. NURSING CARE PLAN
of retained secretions. obstructive airway diseases in interventions, patients who require more than a the patient was able to achieve single bronchodilator. totally effective Administered low flow oxygen airway therapy (2L/min) via nasal cannula clearance through as ordered. complete R: to decrease hypoxemia expectoration of retained secretions. POTENTIAL INTERVENTIONS

y

Dependent y Suction secretions R: to clear airway when excessive secretions are blocking airway.

A case study on Prostatic Cancer with Bone Metastasis (Thorax) (thorax)

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VII. NURSING CARE PLAN
ASSESSMENT DATA (Subjective & Objective Cues) Subjective: NURSING DIAGNOSIS (Problem and Etiology) GOALS OBJECTIVES AND NURSING RATIONALE INTERVENTIONS AND EVALUATION

Activity Intolerance (Level Short term Goals: INDEPENDENT: Short term Goals: 3) related to imbalance 1. Assisted patient in bed to chair ³dili kayo ko kalihok..´ as between oxygen supply After 2hours of thorough Goals met. After and/or wheelchair mobility. verbalized by the patient. nursing intervention, the and demand 30 minutes of R: To prevent injuries client will be able to: thorough Objective: 2. Assisted patient in passive ROM nursing a. Improve heart intervention, the exercises. rate from 105bpm client was able R: to promote venous return - Abnormal decrease of - 100bpm to improve heart RBC 3.96 b. Use identified 3. Positioned client in Semi-fowler¶s rate from 105 - Abnormal decrease of techniques to bpm to 100bpm position. hemoglobin 11.3 enhance assistive Used R: to promote proper lung and - Abnormal decrease of mobility. expansion. To maximize oxygenation for identified hematocrit 34.0 techniques to cellular uptake - pale skin enhance activity - Heart Rate: 105 bpm 4. Encouraged rest periods for client intolerance. and avoid exertion on unnecessary activities. R: to conserve energy consumption.

A case study on Prostatic Cancer with Bone Metastasis (Thorax) (thorax)

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VII. NURSING CARE PLAN
ASSESSMENT DATA (Subjective & Objective Cues) Subjective: NURSING DIAGNOSIS (Problem and Etiology) GOALS OBJECTIVES AND NURSING RATIONALE INTERVENTIONS AND EVALUATION

Ineffective tissue perfusion Short Term: (GI) related to interruption ³galisod ko ug libang« ³ as of arterial blood flow At the end of 3 hours of verbalized by the patient. nursing interventions, the patient will be able to: Objective: a. Improve blood pressure from > Absent bowel sounds 70/40 mmHg to 130/70mm Hg > Melena > Altered blood 70/40mmHg pressure b. Demonstrate various strategies to improve tissue perfusion going to the GI. Long Term: At the end of 24 hours of nursing interventions, the patient will be able to: a. maintain normal blood pressure within the normal range

ACTUAL INTERVENTIONS INDEPENDENT: 1. Assisted client in performing range of motion. R ± to promote venous return 2. Provide small/easily digested food and fluids as tolerated. R ± not to overwhelm the integrity of the GI with the presence of food and to allow blood flow. 3. Encourage rest after meals R: To maximize blood flow to stomach enhancing digestion. 4. Elevate the extremities of the patient within the cardiac reserve R ± to allow venous return DEPENDENT:

Short goals:

term

Goals met. At the end of 3 hours of nursing interventions, the patient was able to Improve blood pressure from 70/40 mmHg to 130/70mm Hg and Demonstrate various strategies to improve tissue perfusion going to the GI. Long Goals term

1. Administer dopamine via IV 14cc/hr. Goals met. At R ± to improve tissue perfusion through the end of 24 correcting hypotension. hours of nursing interventions, POTENTIAL INTERVENTIONS: the patient was

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VII. NURSING CARE PLAN
b. Establish bowel sounds. 1. Prepare Client for Nasogastric insertion R ± for decompression of the GI. able to maintain normal blood pressure within the normal range and establish bowel sounds.

COLLABORATIVE: 1. Refer to nutritionist: Imbalanced Nutrition, less than body requirements.

A case study on Prostatic Cancer with Bone Metastasis (Thorax) (thorax)

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