Zuellen Mae G.

Bedaño BSN 4-A

Case Scenario :
Mr. Lewis, aged 57 years is admitted to the hospital at 8 pm for left lower lobe pneumonia. His
vital signs are as follows: T- 38.1 *CHR 90 bpm and regular, BP 142/74 mmHg, RR 28. He has
a weak cough, diminished breath sounds over the left lower lung field, and coarse rhonchi over
the mid tracheal area. He can expectorate some sputum, which is thick and grayish-green. He
has a history of stroke. Secondary to the stroke, he has impaired gag and cough reflexes and
mild weakness on the left side. Formulate a Nursing Care Plan for Mr. Lewis.

Cues Nursing Outcome Interventio Rational Evaluatio Discharg

Diagnosis Criteria n e n e
Planning

Subjective: Ineffective Short Term: Independe Indepen Short M​edicatio

airway After 1hr of nt​: dent​ : term: n: Advise
clearance Nursing patient
related to intervention •Monitor •Provides After 1hr of and
Objective: thick the patient rate, a basis Nursing significan
sputum will verbalize rhythm, for interventio t others
•T- 38.1 secondary expectorate/c depth, and
evaluatin n the regarding
•BP 142/74 to lear effort ofg patient his home
mmHg pneumonia secretions respiration
adequacy verbalized medicatio
•RR 28 as readily. s. of expectorat ns:
evidenced ventilatio e/clear
•weak cough by n. secretions E​nvironm
•diminished Temperatur •Note •Presenc readily. ent:Enco
breath e of 38.1, chest e of nasal urage
sounds over BP 142/74 Long-term: movement flaring client and
the left lower mmHg,RR After 1 week s, watch for and use family to
lung field of Nursing symmetry, of provide a
28 ,weak
•coarse intervention use of accessor clean,
cough, the patient accessory y Long-term peaceful,
rhonchi over diminished will be able muscles, muscles : stress-fre
the mid breath to maintain and of After 1 e and
tracheal sounds airway supraclavic respiratio week of well
area over the patency by ular and ns may Nursing ventilated
• Can showing: intercostal occur in interventio environm
left lower
expectorate lung muscle response n ent
a. Norm retractions. to the patient conduciv
some field,coarse al ineffectiv maintained e for
sputum(thick rhonchi breat e airway recovery
and over the h ventilatio patency by and
grayish-gree mid sound n. showing: healthy
n) tracheal s •Elevate •To take living.
when head of the advantag c. Nor
area and
bed/chang e of mal T​reatmen
can auscu e position gravity bre t: Review
expectorat ltated every decreasin ath medicatio
e some b. Respi 2hours and g sou n that will
ratory prn pressure nds be take
sputum(thic
rate on the wh home
k and of diaphrag en and
grayish-gre 16-20 m and aus stress
en) breat enhancin cult importanc
hs/mi g ate e of
n drainage d following
of/ventilat d. Re prescribe
ion to spir d
different ator regimen.
lung y
segments rate H​eath-Te
•Promote •Adequat of aching:
systemic e fluid 16- •Discuss
fluid intake 20 w/ patient
hydration, enhances bre his
as liquefacti ath understa
appropriate on of s/m nding of
. pulmonar in his
y condition
secretion and how
s and it affects
facilitates his body.
expectora •Encoura
tion of ge
mucus. frequent
•Oral •To clear rest
suction out periods
prn. secretion and teach
s when it patient to
blocks pace
the activity.
airway. •Educate
•Assists patient or
•Auscultate in significan
lung evaluatin t other
sounds g proper
after prescribe breathing
treatments d ,
to note treatment coughing,
results. s and and
client splinting
outcomes methods.
. •Encoura
Depende ge
Dependen nt: smoking
t:
•Provide •A variety cessation
respiratory of and avoid
medication respirator Alcohol
s(e.g., y therapy
drinking
nebulizer, treatment
expectoran s may be
t, used to O​ut-patie
bronchodil open nt:Instruct
ators) and constricte the family
oxygen, d airways to seek
per and consultati
doctor’s liquefy
on
orders. secretion
s. follow-up
check-up
•Administer •For as
and hydration advised
Monitor IV D​iet:
fluids as •Strictly
prescribed
follow the
Collaborat Collabor prescribe
ive: ative : d diet.
•Provide
and •For S​upport/
implement nutritional Spiritual:
prescribed needs Encourag
dietary
modificatio e the
ns family to
•Monitor •Helps to seek
lab studies monitor spiritual
the support
patient's groups or
condition
communit
and the
effectiven y
ess of resources
nursing for the
care. patient.
•Refer •Exercise
patient for promotes
evaluation conditioni
of exercise ng of
potential respirator
and y
developme muscles
nt of and
individualiz patient’s
ed exercise sense
program. of
well-bein
g.