TASK ENGLISH

ABOUT NURSING CARE PLAN

DI SUSUN OLEH :

NAMA : INDRI YAPLALIN

CLASS : MORNING

NPM : 1420117104

STUDY PROGRAM : KEPERAWATAN

SEMESTER : VI

SEKOLAH TINGGI ILMU KESEHATAN (STIKes)

MALUKU HUSADA

2020
 Student Nursing Care Plan Template

Client : Ridwan

Care plan intiated by: Indri yaplalin

Date: 29-08-2020

ASSESSME DIAGNOS OUTCOM INTERVENTIO RATIONAL EVALUATI

NT IS ES NS E ON
(+) Dyspnea Impaired Patient will 1.Assess 1.Manifestati Patient
(+) Abnormal gas maintain respirations: note ons of maintained
breath sounds exchange optimal gas quality, rate, respiratory optimal gas
RT exchange. rhythm, depth, distress are exchange
Heart Rate collection use of accessory dependent AEB normal
= 128bpm of mucus in muscles, ease, on/and respiratory
airways. and position indicative of rete, (-)
Restlessness assumed for easy the degree of dyspnea,
breathing lung effective
(+) involvement coughing
productive 2. Elevate head and techniques
cough. and encourage underlying
frequent position general health
changes, deep status as
breathing, and patients will
effective adapt their
coughing. breathing
patterns to
facilitate
effective gas
exchange

2.These
measures
promote
maximum
chest
expansion,
mobilize
secretions and
improve
ventilation
 Nursing Care Plan Template (5- column Format)

Client : Ridwan

Care plan intiated by: Indri Yaplalin

Date: 29-08-2020

Assesment Nursing Goals and Nursing Evaluation

Diagnosis Outcomes Interventions
(+) Dyspnea Ineffective After 8 hours 1. Provide a quiet - Patient
(+) Abnormal airway clearance nursing environment and maintained
breath sounds RT tracheal intervention, the limit visitors optimal gas
bronchial patient will during acute exchange AEB
Heart Rate inflammation, display/maintain phase as normal
= 128bpm edema formation, patent airway indicated. respiratory rete,
increased sputum with breath (-) dyspnea,
Restlessness production AEB sounds clearing: 2. Pace activity effective
coughing, absence of for patients with coughing
(+) productive dyspnea, dyspnea, reduced activity techniques
cough. purulent sputum cyanosis, as - After 8 hours of
evidenced by 3. Assist patient nursing
keeping a patent to assume intervention, the
airway and comfortable patient was able
effectively position for rest to maintain
clearing and sleep patent airway
Secretions. with breath
sounds clearing
AEB absence of
dyspnea,
cyanosis, and
effectively
clearing
secretions
 Sample Nursing Care Plan Format (4 columns)

Client : Ridwan

Care plan intiated by: Indri yaplalin

Date: 29-08-2020

NURSING GOALS & INTERVENTIONS EVALUATION

DIAGNOSIS OUTCOMES
Ineffective airway After 8 hours nursing 1. Assess the rate, After 8 hours of
clearance RT tracheal intervention, the rhythm, and depth of nursing intervention,
bronchial patient will respiration, chest the patient was able to
inflammation, edema display/maintain movement, and use of maintain patent
formation, increased patent airway with accessory muscles. airway with breath
sputum production breath sounds sounds clearing AEB
AEB coughing, clearing: absence of 2. Elevate head of absence of dyspnea,
dyspnea, purulent dyspnea, cyanosis, as bed, change position cyanosis, and
sputum evidenced by keeping frequently. effectively clearing
a patent airway and secretions
effectively clearing 3. suction as
Secretions. indicated: frequent
coughing,
adventitious breath
sounds, desaturation
related to airway
secretions.
 Nursing care plan template (3-column format)

Client : Ridwan

Care plan intiated by: Indri yaplalin

Date: 29-08-2020

Nursing Diagnosis Outcomes and Evaluations Nursing interventions

Activity intolerance RT --No reports of dyspnea 1. Provide a quiet environment
exhaustion associated with -- Vital signs within normal and limit visitors during acute
interruption in usual sleep range phase as indicated.
pattern because of discomfort,
excessive coughing, and 2. Pace activity for patients
dyspnea with reduced activity

3. Assist patient to assume

comfortable position for rest
and sleep