NURSING CARE PLAN

ROOM # 618 6TH FLOOR

City Of General Trias Doctors Medical Center

November 28-29, 2019

Submitted To
Ruth A. Ambon RN, RM, MAN
Clinical Instructor

Submitted By
Cabe, Bridget Hayde Melan C.
Pasquito, Rica Jamil
BSN 201
 NOVEMBER 28, 2019
S/O (Data) A P I E
(Focus) (ACTION) (RESPONSE)
Nursing Background Long Term Short Term Intervention Rationale Evaluation
Diagnosis Knowledge

SUBJECTIVE > Tepid sponge bath = hygiene purposes.

Ineffective Innefective To facilitate the Patient will performed Comfortability Goal partially met,
“sumasakit dibdib ko pag airway airway clearance maintenance of a promote an patient can manage
clearance is the inability to supply of oxygen optimal > Encouraged the pain but the
= Oral fluid replacement is
umuubo ako” as related to clear secretions to all body cells. spontaneous adequate liquid intake indicated for mild fluid cough is still
excess or obstructions breathing deficit and is a cost- uncontrolable.
verbalized by the patient tevacious from the pattern that effective method for
secretions. respiratory tract maximize replacement treatment.
to maintain a oxygen and
> Changed linen = important for
OBJECTIVE clear airway. carbon dioxide
exchanged in preventing the
> espressions of pain in transmission of germs
the lungs.
chest when coughing > Taught how to = Health teaching for
cough effectively patient
> shortness of breath
> Inform patient and
PR: 111 RR: 23 = to produce the
family about
relaxation technique body's natural
to improve breathing relaxation response
pattern

> Instructed to take

adequate rest = To prevent fatigue

> Watch out for signs = To prevent zero

and symptoms of medication errors
respiratory distress

> Maintain patient in

a semi-fowlers = To help the patient
position breathe more easier

> Instructed patient to

= To prevent
adhere dietary
regimen sickness
 NOVEMBER 29, 2019
S/O (Data) A P I E
(Focus) (ACTION) (RESPONSE)
Nursing Background Long Term Short Term Intervention Rationale Evaluation
Diagnosis Knowledge

SUBJECTIVE > changed linen = Important for

Sleep Sleep deprivation To facilitate the After 8 hours preventing the Goal not met
“hindi ako makatulog” as deprivation is most maintenance of of intervention, transmission of germs patient still cannot
related to commonly regulatory patient will sleep.
verbalized by the patient health defined as a state mechanisms and identify and use > performed tepid = Hygiene purposes,
condition in which an functions. measures that sponge bath comfortability
individual will increase
experiences rest or sleep on > encouraged patient
to take naps during = to meet sleep
OBJECTIVE prolonged time
the day requirements
periods of time
> weak looking without sleep. > maintened comfort
> not in the mood in environment and
hygiene
= for comfortability
and hygiene
> taught patient the purposes
use of non
pharmacological
= to produce the
techniques
(relaxation) body's natural
relaxation response