VISION Republic of the Philippines MISSION

A premier university in CAVITE STATE UNIVERSITY Cavite State University shall provide
historic Cavite recognized Don Severino Delas Alas Campus excellent, equitable and relevant
for excellence in the educational opportunities in the arts,
Indang, Cavite
development of morally science and technology through quality
upright and globally instruction and relevant research and
competitive individuals. development activities. It shall produce
College of Nursing professional, skilled and morally upright
individuals for global competitiveness.
NURSING CARE PLAN
Name of Patient (initial): MA Sex: Female
Age: 4 years old OB Score:
ASSESSMENT NURSING PLAN INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective: Ineffective STG: 1. Establish rapport 1. To gain pt’s trust
“nahihirapan siyang breathing After 2 hours of nursing 2. Assess pt’s 2. To obtain
huminga kasi inuubo pattern r/t intervention, the client condition baseline data
siya ngayon, may hika presence of will: 3. Assess the VS 3. To track
pa naman siya.” as secretions AEB  manifest signs of 4. Auscultate breath important
decreased
verbalized by the productive sounds and changes
respiratory effort
client’s mother cough AEB absence of assess airway 4. To check for
secondary to dyspnea pattern abnormal breath
Objective: asthma  verbalize 5. Encourage deep sound
 Wheezing upon understanding of breathing and 5. To help minimize
inspiration and causative factors coughing difficulty in
expiration and demonstrate exercises breathing
 Dyspnea behaviors that 6. Demonstrate 6. To decrease air
 Coughing with would improve diaphragmatic and trapping and for
sputum (yellow breathing pattern pursed-lip efficient
LTG:
and sticky) breathing breathing
After 1 week of nursing
Vitals: 7. Encourage 7. To prevent
intervention, the client
Temp: 36.6 will maintain optimal increase in fluid fatigue
BP: breathing pattern, AEB intake 8. To prevent
PR: 77 relaxed breathing, 8. Encourage to limit situation that can
RR: 30 normal respiratory rate or physical activity alleviate the
pattern, and absence of condition
dyspnea.