NURSING CARE PLAN

ASSESSMENT EXPLANATION OF THE PLANNING IMPLEMENTATION RATIONALE EVALUATION

PROBLEM
October 12, 2018 Inhales microorganisms After 5 hours of nursing After 5 hours of nursing
intervention the client will be  Monitor  To indicative of intervention the client wasn’t able
Objective data: able to: respiration and respiratory distress or to:
 Adventitious Transmitted to alveoli  Manifest absence of breath sounds. accumulation of  Manifest absence of
sound crackles upon  Position head secretion. crackles upon
(crackles) auscultation appropriate for  To open or maintain auscultation
 With Less function (impaired gas  Attain normal condition. open airway.  Attain normal pattern of
mechanical exchange) pattern of 20cpm  Hooked to  Use as aid in 20cpm as evidenced by
ventilator mechanical treatment. respiratory rate 32cpm
Vital signs: ventilator.  To relaxes bronchial
BP: 110/70 Mucus production (inflammatory  Administer muscle resulting in
PR: 162 bpm reaction) medication such expansion of the  Goal not met.
RR: 32cpm as Broncho- bronchial air
Temp: 36.6 dilators. passages.
SPO2: 98% phagocyte produce

Nursing Diagnosis:
Ineffective Airway accumulation of exudates in
Clearance related to alveoli
excessive mucus
and exudate in the
alveoli mucus secretion

ineffective airway clearance

 ASSESSMENT EXPLANATION OF THE PLANNING IMPLEMENTATION RATIONALE EVALUATION
PROBLEM
Objective: Decrease in oxygen, resulting in Within 8 hour of rendering  Monitor and  Assess trends in LOC Within 8 hours of rendering
Vital signs failure to nourish tissues at therapeutic nursing care, the document and potential for therapeutic nursing care, the
T: 36.6 capillary level. patient will have: neurological status. increased in ICP and patient wasn’t able to have:
PR:162bpm  Improvements in useful in determining  Improvements in
RR:32cpm terms of his vital location, extent, and terms of his vital
BP:110/70 signs including blood progression or resolution signs including blood
pressure and  Monitor vital signs of CNS damage. pressure and
improved cerebral noting:  Irregularities in these are improved cerebral
tissue perfusion. hypertension or indications of tissue perfusion.
Nursing diagnosis: hypotension, heart problems/complication of  Goal not met.
Ineffective Cerebral rate, pupillary the brain functions.
Tissue Perfusion reaction and
related to post illness respirations.
 Position client with
head slightly
elevated and in
neutral position.  Reduces arterial
pressure by promoting
venous drainage and
may improve cerebral
circulation and perfusion.
 ASSESSMENT EXPLANATION OF PLANNING IMPLEMENTATION RATIONALE EVALUATION
THE PROBLEM
Objective: Entry of noxious After 5 hours of nursing  Monitor and record vital  To obtain baseline data. After 5 hours of nursing
 Tachycardia particles of gases to the intervention the client: signs.  To evaluate degree of intervention the client wasn’t :
Vital signs lungs  Manifest absence of compromise.  Manifest absence of
T:36.6 crackles upon crackles upon
PR:162bpm auscultation  Auscultate breath auscultation
RR:32cpm Release of mediators  Attain normal pattern sounds, note areas of  Attain normal pattern of
BP:110/70 of 20cpm decrease/adventitious  To enhance lung 20cpm as evidenced by
breath sounds as well as expansion. respiratory rate of
Nursing diagnosis: Abnormal inflammation fremitus. 32cpm.
Impaired Gas Exchange of the lungs  Elevate the head of the
related to Alveolar- patient.  For the pharmacological  Goal not met.
capillary membrane of patients condition.
Chronic inflammation
 Suction when needed.  Suctioning is required
when cough is ineffective
Scar tissue formation for expectoration of
 Monitor pulse oximetry secretions.
and ABGs.  For the pharmacological
Narrowing of airway of patients condition.
lumen
 Use as aid in treatment.
 Administered prescribed
Airflow limitations medications as ordered.
 Hooked to mechanical
ventilator
Impaired gas exchange

Crackles
 ASSESSMENT EXPLANATION OF THE PLANNING IMPLEMENTATION RATIONALE EVALUATION
PROBLEM
Objective: Occlusion in Short term:  Assessed for and  Cerebral perfusion is At the end of 8 hours nursing
 Irregular the artery After 30 minutes of nursing document the ff: directly related to cardiac interventions, the goal was
rhythm of interventions, the client will be  Mental status output and aortic perfusion not met as evidenced by:
pulse noted Decreased able: pressure and is influenced  PR- 162bpm
Vital signs blood supply  Demonstrate by hypoxia and electrolyte
T:36.6 hemodynamic stability and acid base variations.
PR:162bpm (blood pressure and
RR:32cpm Decreased cardiac output) by 20-  Crackles may develop
BP:110/70 venous 30% as revealed in
return cardiac monitor.  Hypotension related to
hypo perfusion
Nursing diagnosis: Long term:  Lung sounds
Decreased Cardiac At the end of 8 hours nursing  Bradycardia may be
output related to altered interventions, the client will be  Blood pressure present because of vagal
heart rate Decreased able to: stimulation.
amount of blood expelled  Demonstrate  Heart sounds  Urine output <0.5ml/kg/hr
by ventricles hemodynamic stability may reflect reduced renal
(blood pressure and  Urine output perfusion and glomerular
Decreased cardiac output cardiac output) by 31- filtration as a result of
80% as revealed in cardiac output.
mechanical ventilator.  Decreased may indicate a
 Peripheral perfusion decreased cardiac output.
ASSESSMENT EXPLANATION OF PLANNING IMPLEMENTATION RATIONALE EVALUATION
THE PROBLEM
Objective:  The cardiac After 8 hours of nursing  To established baseline After 8 hours of nursing
system can intervention, client will  Monitor vital signs data. intervention, client wasn’t
Vital signs: become demonstrate increased  Adventitious sounds demonstrate increased
PR:162bpm overwhelmed perfusion with (crackles) and extra perfusion with manifestation of
RR:32cpm because the manifestation of regular  Auscultate lungs and heart heart sounds (S1) are regular pulse characteristics.
BP:110/70 heart is forced pulse characteristics. sounds. indicative fluid excess.  Goal not met.
T:36.6 to pump Pulmonary edema may
SpO2: 98% against rising develop rapidly.
peripheral  Activities that requires
Nursing diagnosis: resistance. too much work load
Ineffective Peripheral  Cautioned to avoid activities that leads to heart stress.
Tissue Perfusion increase the heart’s work load.
related to fluid overload
 Monitored and recorded intake  To determine fluid
and output. volume relative to
oxygen transportation
and circulation.