COR JESU COLLEGE

Sto. Rosario, Tres De Mayo Digos City

Health Sciences Department

NURSING CARE PLAN

NAME: Mainit, Ignacio AGE: 92 y/o SEX: Male CIVIL STATUS: Married
RELIGION: Roman Catholic IMPRESSION DX:HCVD, COPD
CHIEF OF COMPLAIN: Dyspnea, cough & body malaise PHYSICIAN: Dr. Reyes
 PROBLEM SCIENTIFIC GOALS/ NURSING RATIONALE EVALUATION
BASIS OBJECTIVES INTERVENTION
CRITERIA
(August 23, (August 23, 2010
2010 at 4:00 around 10:00 pm)
pm)
Chronic cough Within the span of  Establish rapport  To gain trust and Goal partially
S>”Daghan and sputum care, the patient will cooperation of met: Within the
kayo siya ug production often maintain airway the patient span of care, the
plema mao na precede the patency, as patient
maglisud siya development of evidence by: maintained
 Take and monitor  Serves as
ug ginhawa”, the airflow airway patency,
patient’s vital signs baseline data
as verbalized limitation. The a. respiratory as evidenced by:
by the watcher mucus- rate will  Assess respiratory  Provides a basis
producing maintain at rate for evaluating
a. respiratory
O>vital sign: bronchial wall normal range: rate decreases
adequacy of
RR: 35 cpm hypertrophy and RR= 12-20 cpm; from 35 cpm
ventilation
(tachypnea) increased in b. maintain a to 24 cpm;
>paO2 of 98% number paO2 at normal b. expectorat
>abnormal  Note chest  Use of accessory
consequently level of 95-100% ed secretions
breath sounds: movement; use of muscles of
the increase c. expectorate through
crackles upon accessory muscles respiration may
mucus secretion secretions suctioning;
auscultation during respiration occur in response
affect the flow of without to ineffective c. demonstra
>patient is air and assistance or at ted behaviors
dyspnic ventilation
exchange of gas the level of to
>use of  Turn patient to
and may one’s ability; improve/maint
accessory sides every two  To prevent
predispose the d. demonstrate ain airway
muscles for hours pneumonia and
client to behaviors to clearance;
respiration bed sores
plugging and improve/maintai d. demonstra
observed infection. Long ted absence/
n airway  Document  Expectorations
>excessive standing reduction of
clearance; respiratory may be different
sputum seen infection may congestion but
e. demonstrate secretions: when secretions
during result in the still with
absence/ character and are very thick.
suctioning destruction of crackles;
reduction of amount of sputum
>crackles lung tissue. e. allayed
congestion with  Positioning helps
heard when With infection, restlessness;
breath sounds maximize lung
patient cough the amount of clear, noiseless  Maintain patient on expansion f. participate
>with sputum becomes respiration; d in treatment
repiratory aid more copious moderate high
f. allay regimen,
attached (O2 and purulent. back rest  To maintain
restlessness; within the level
via nasal Breathlessness adequate airway
g. participate in of
cannula at on exertion  Check for patency
treatment ability/situatio
4LPM) occurs with obstructions:
regimen, within n; and
>elevated increasing accumulation of
shoulders the level of secretions
g. respiratory
severity.  For faster
ability/situation; aid still
when recovery and
and attached (O2
inspiration  Encourage patient healing of the
h. identify via nasal