URDANETA CITY UNIVERSITY

San Vicente West, Urdaneta City, Pangasinan 2428

COLLEGE OF HEALTH SCIENCES

Bachelor of Science in Nursing

NURSING CARE PLAN (NCP)

Name of Student: Manaois, Darlene Dana S Year Level and Group: III-4A

Affiliating Agency/Area: Month/Year of Exposure:

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

(at least 10)

Subjective: Problem, Etiology, Signs Short Term Goal: Independent: Short Term Goal Evaluation
(P.E.S.) format S.M.A.R.T. + Evidence
“Dalawang lingo  Establish rapport  To gain pt.’s trust After 2 hrs of ni pt is able to
na pong umuubo Ineffective breathing After 2 hrs of nursing verbalize understanding of
ang anak ko” as pattern related to intervention, pt will:  Assess pt.’s condition  To obtain baseline data causative factors and
verbalized by the bronchospasm as demonstrate behaviors that would
mother evidenced by persistent  Verbalize
improve breathing pattern and
cough understanding of
 Monitor v/s and record  To track important demonstrate pursed-lip breathing
causative factors
changes and diaphragmatic breathing.
and demonstrate
behaviors that
 Auscultate breath sounds  To check the presence of
would improve GOALS MET
and assess airway pattern adventitious sounds
Breathing pattern
 demonstrate
 Regularly check the  Upright position or semi-
pursed-lip
patient’s position so that Fowler’s position allows
breathing and
he or she does not slump increased thoracic
diaphragmatic
down in bed. capacity, full descent of
breathing
diaphragm, and increased
lung expansion
preventing the abdominal
contents from crowding.
Objective: INFERENCE Long Term Goal: Long term Goal Evaluation
(at least 5) Scientific Explanation S.M.A.R.T.+ Evidence
(Diagram Form) After 3 days of ni pt is able to
 Clear eyes After 3 days of nursing maintain optimal breathing
 Boggy nasal Presence of secretions intervention, pt will:  Educative pattern as evidenced by relaxed
mucosa w/ in bronchi  Encourage deep  Promote chest expansion. respiratory rate
clear dc  Maintain optimal breathing exercises And it allow your body to
 Rhonchi and breathing pattern fully exchange incoming GOAL MET
wheezes are as evidenced by oxygen with outgoing
carbon dioxide
present relaxed respiratory
Air blockage
when rate
auscultated Dependent:
 Skin is dry 

Insufficient air in the  Provide respiratory  Corticosteroids reduce

body medications and oxygen, inflammation in the
Vital Signs: per doctor’s orders. airways that carry air to
the lungs and reduce the
T- 39.2
mucus made by the
P- 110 bpm bronchial tubes.
Inability to maintain
RR-28 bpm  Reinforce low salt, low fat  To mobilize secretions
clear airway diet as ordered
BP- 90/60 mmHg
 Educate patient about  This information promotes
medications: indications, safe and effective
dosage, frequency, and medication
possible side effects. administration.
Obstruction heightened
Incorporate
by bronchospasm

Interdependent/Collaborative

 Refer patient for  Exercise promotes

evaluation of exercise conditioning of
Ineffective breathing potential and respiratory muscles
pattern development of and patient’s sense
individualized exercise of well-being.
program.

Checked by: _________________________________ Date: ____________________

Clinical Instructor’s Name and Signature