NURSING CARE PLAN

Assessment Diagnosis Goal Planning Interventions Rationale Evaluations

Subjective Ineffective Effective  To assess the  RR-34/min  It helps to know about Goal was
data: airway breathing patient’s condition. patient’s condition partially met
“I have
clearance pattern  To Place the patient  Patient was kept in semi  Relaxation and easy, as patient
excessive cough
” related to will be in comfortable fowlers with a pillow under prolonged exhalation reported of
inflammation, maintaine position. the shoulder. maximize lung relieve of
Objective
accumulation d within  To help the patient  deep breathing and expansion while cough to some
data:
Patient of secretion half an to perform deep coughing exercises was minimizing energy extent after
manifested: hour breathing and demonstrated and O2 expenditures. nursing
 Restlessnes
coughing exercises.  Adequate oxygen intervention.
s
 Excessive  To administer O2 as helps to correct the
cough ordered hypoxemia and
 Flushed  Encouraged him to drink facilitate breathing.
 To hydrate the
face
patient adequately. plenty of warm soup, hot  It helps to liquify the
 RR-34/min
water. bronchial secrection
 To administered
 Administered nebulization and easy to come out.
Nebulization
as prescribed
therapy as
prescribed  Informed health teaching  Bronchial irritant
was given about the role of causes broncho
 To instruct the
bronchial irritants such as constriction and
patient to avoid
cigarette, cold, dust and increase mucous
bronchial irritants
encourage to avoid it. secrection, which
such as cigarette,
cold, dust. interfere with airway
clearance.

Assessment Diagnosis Goal Planning Interventions Rationale Evaluations

41
 Subjective Impaired The  To use supplemental  The act of eating Patient
data: dietary intake patient O2 during mealtime, as increase O2 demand. progressively
Patients related to will take
sever cough ordered. started to eat
“I am unable meal
and
to eat due to without  To provide oral care  Assisted to do oral care  It helps to increase and drink.
environmental
odor episodes including brushing and saliva secretion.
cough and
of acute
odor coming shortness flushing of mouth.
from toilet” of breath  To maintain
within  Kept patient in high fowler  Proper positioning
comfortable position
Objective two days position during mealtime helps to decreased
by
data: shortness of breath.
 To provided frequent  Instructed patients son to
-Patient’s  Small meals require
and small meals. provide him frequent and
food intake is less O2 for eating and
 To encouraged to take small meals that comtained
very less. digestion.
- Patients bed high protein, low high protein, low
 A diet with low calorie
is near to carbohydrate and fat carbohydrate and fat
will meet the
toilet and supplements. supplements.
metabolic demands
dustbin.  To instructed food  Instructed patients son to
without increasing
given after cleaning of provide him food after
CO2 production.
the room cleaning of ward by ward
 It helps cut off the
attendentants.
environmental bad
 To monitor body  Weight was taken daily
odor
weight daily during my duty and it is
 To asses edema
consstant(61kg)

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Assessment Diagnosis Goal Planning Interventions Rationale Evaluations
Subjective Impaired  To maintain the  Maintain the bed by  Proper bedding Goal was
data: Patient
Patients sleeping bed by doing doing proper bed making helps to relax not achieved
will
“I couldn’t pattern proper bed  Instructed the patient to as patient
take nap
sleep
related to at least making do passive exercise could not
properly
during night environmen 2 hour  To instruct the  Assisted in daily  Feels exertion and take nap as
due to light tal light and patient to do maintenance of personal can be taken nap lack of
and noise” noise hospital
passive exercise hygiene
Objective  To assist in daily  Controlled the visitors facility.
data:
maintenance of  It helps feeling
patient seems
personal hygiene Instructed cover the freshness
tired and
anxious, window by cur ton when
 To control the
eyelids taking nap
visitors
swollen
 To instruct to  It helps to avoid
cover the window unpleasant noise
by curtain when  It helps easy to nap
taking nap by avoiding
unnecessary light

Assessment Diagnosis Goal Planning Interventions Rationale Evaluations

43
Subjective Activity Activities  To educate patient to  Educate patient to coordinate  It helps to avoid Goal was
data: intolerance
tolerance coordinate diaphragmatic breathing with excessive fatigue or partially
Patients related to
hypoxia level will diaphragmatic activities. dyspnea achieved as the
Objective be breathing with  Encourage patient to do self- patient shows
data: improved activities. care, like personal hygiene,  It helps to involve in interest in
within  To encourage patient walking dressing etc. own care and prepares daily activities
three to do self-care, like her for manage in but small
days. personal hygiene,  Support patient in establishing home care after activity patient
walking dressing etc. in regular regimen of discharge. developed
exercise.  It helps to avoid Shortness of
 To support patient in hesitation in self-care, breathing.
establishing in regular  Monitor respiratory status, and increase
regimen of exercise. including breathing sounds, motivation.
signs and symptoms of  It helps to assess early
 To monitor respiratory status during activity tolerance level
respiratory status, activities. in the patient
including breathing  It prevent loss of
 Kept conversation short and
sounds, signs and energy and prevent
instructed visitors not to take
symptoms of tiring
visits long time
respiratory status
during activities.

 To kept conversation
short and instructed
visitors not to take
visits long time

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Assessment Diagnosis Goal Planning Interventions Rationale Evaluations
Subjective Fluid Patient  To record the  Recorded the intake and  To check the Goal was
data: volume
patient c/o will intake and output output chart negative and fully
deficit
dizziness related to maintai chart  Monitored vital signs, positive fluid achieved as
,weakness inadequate
ned  To monitor vital skin turgor and mucus balance patient
intake of
Objective fluid, fever. adequat signs, skin turgor membrane  To check the fluid could not
data: e fluid and mucus  Maintained the accurate and electrolyte develop
Patient BP volume dehydration
membrane IVF according to order balance
was 90/60
Temperature- during  To maintain the  Encouraged to take , intake and
1000F hospitali accurate IVF plenty of oral fluid  To prevent the output were
zation according to fluid overload balance in
Antipyretic Paracetamol during
order  To help in fluid
given P/O given regularly hospitalizati
 To encourage to balance as body
as ordered on.
take plenty of oral required
fluid  To reduce the
 To administers fever and
Antipyretic as ultimately prevent
prescribed. diaphoresis

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PROGRESS NOTES
Date Nursing Report
2076/11/0 Patient was alert, conscious and oriented. Patient is coughing continuosly so
4 patient is kept in semi-fowlers position and nebulization was given. Patient was
3rd DOA instructed for deep breathing and coughing exercise.
B.P=80/60mm of hg, R.R=34/min, Pulse=114/min, Temp. =98.4ºf, SPO 2 89% in
room air.
2076/11/0 Patient's general condition was fair. Patient complaining of lass of interest in food.
5 Patients son was asked to provide him with small food frequently.
4th DOA B/P- 90/70 mmof Hg, RR- 20/min, P- 98/min, T- 98 ºf, SPO2- 92%
2076/11/0 Patient's general condition was fair. There was no complain of pain but patient
6 want to go home.
5th DOA B/P- 90/60mm of hg, RR- 22/min, P- 98/min, T- 98 ºf, SPO2 96%
2076/11/0 Patient's condition was fair. No any fresh complain. He was planned for discharge
7 so; discharge teaching was given to patient. He was also encouraged for increase
6th DOA oral fluid intake and to avoid bronchial irritants such as cigarette, cold, dust.

DIVERSIONAL THERAPY
It is one of the important parts while taking care of the patient. For my patient as the
diversional therapy I provide an opportunity to express his feelings, talked about his
previous lovely experiences, about some of the religious beliefs etc. I discussed with his
family member about his interest. He felt happy to express about his experiences, his
feelings etc. I asked to bring a book so that he can read.So diversion therapy provided to
him is especially ventilation of his feeling, pleasant life experences and whatever he
wants to share with me.

DISCHARGE TEACHING

Informal health teaching was provided since the day of meeting with patient. Discharge
teaching was also provided. They are as follows:

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 Adequate fluid intake:- advice patient to take 3-4 lts per day.
 Diet:- advice patient to take high calorie and high protein diet. Take small but
frequently. High protein are available in egg, meat, peas, beans, soyabeans, pulses,
legume etc.
 Personal hygiene:- It includes oral care, hair care, nail care, bathing etc. it is
important to prevent spread of microorganism from one person to another.
 Rest and sleep:-sleep 6 to 8 hrs and rest frequently at day time.
 Exercise:- deep breathing and coughing exercise
 Prevention of Infection:- take vitamin c rich food and donot smoke and come in
contact with smoke and dust.
 Medication:- take proper medicine as prescribe on time
 Follow up visit: after 1 week in medical OPD.

Discharge Medicine

 Tab Farin 2.5/5mg PO OD on alternate day

 Tab Amilax 1tab PO OD AM
 Tab Lanoxin 1tab PO OD(7 days)
 Syp Mucodyne 10ml PO TID for 5days
 Tab cefadroxyl 500mg PO BD for 7days
 Cap Fluclox 500mg PO ID for 7days

LEARNING FROM THE CASE STUDY

During the course of clinical assignment in surgical unit of MMTH, I got opportunity to
know in detail about Pneumonia. I gained more insight regarding disease process. I took
comprehensive history, did physical examination and provided nursing care by applying
Environmental theory. The lesson learned from this case study is:

 Gained in depth knowledge about Pneumonia, including pathophysiology, signs,

treatment and nursing management.

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 Gained knowledge about how to take care of patient with Pneumonia.
 Developed knowledge and skills in history taking, physical examination, application
of nursing theory and nursing process in patients with Pneumonia.
 Learned the normal developmental task of middle adulthood and also compared with
patient.
 Got information about normal and abnormal values of different laboratories
investigation.
 Participated in care of patient on the basis of well plan nursing care plan.
 Learned hospital management policies of MMTH.

CONCLUSION

Mr. Ram Chandra Regmi 55 year old male was admitted in hospital with diagnosis
Pneumonia for management. His total stay in hospital was 4 days. During the period of
hospitalization, Patients general condition improved gradually from admission day and
was discharged with medicines and some health advices.

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REFERENCES

• Janice. L.Hinkle, Kerry H. Cheever. (2014). Brunner &suddarth’s Text Book

th
of Medical Surgical Nursing (13 ed). New Delhi: Wolters Kluwer.

nd
• BT Basavanthappa, (2009). Medical Surgical Nursing (2 ed). Jaypee
Brothers India.
• Black, J. M. (2009). MedicalSurgical Nursing; Clinical Management for

th
Positive Outcomes. 8 edition. India; Elsevier.

th
• The Lippincott Manual of Nursing Practice (2001), 7 edition, Lippioncott
Williams and Wilkins.
• Murray, R. B. &Zentner, J .P. (2001). Health Promotion Strategies Through
the Life Span. New Jersy; Prentice-Hall Medical Publishers
• George, J. B. (2011). Nursing Theories: The Base for Professional Nursing

th
Practice (6 ed.). New Delhi, India: Dorling Kindersley.

• http://nandanursing.com
• www.lung.org 
• www.bmicalculator

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