Davao Doctors College

General Malvar St., Davao City

Nursing Program

NURSING CARE PLAN

Name of Patient: D.N. Date of Admission: August 25,

2021 Room: 404B
Age: 52 y/o Sex: F Civil Status: N/A Chief Complaint: SOB on exertion, bilateral foot swelling, Left-sided weakness
Religion: N/A Attending Physician: Dr. Kulintang

Date/Tim Nursing Goals and

Cues Interventions Rationale Evaluation
e Diagnosis Objectives
Aug 25, SUBJECTIVE Ineffective SHORT TERM a. Monitor and - To obtain SHORT TERM
2021 CUES breathing GOALS record vital baseline
pattern r/t right After 1-2 hours signs data After 1-2 hours of
“Katong bag-o pleural effusion of nursing nursing intervention
palang wala pa secondary to intervention: b. Assess - Early the patient’s
ko na stroke, Congestive breath identificati comfort increases
Heart Failure - Patient will sounds, on of as evidenced by:
gasugod na
report respiratory respiration
lisdan ko feeling rate, depth problems
ginhawa SCIENTIFIC
BASIS comfortabl and rhythm allow - Patient’s vital
usahay. Pero e when timely and signs is
after na ato, ga breathing appropriat within
A pleural
sige na atake. - Patient’s e initiation established
effusion is a
Lisdan nako respiratory of limits.
buildup of fluid
rate interventio - Patient
ginhawa”, as between the
remains ns demonstrate
verbalized by layers of tissue
within d correct
the patient that line the
established c. Provide - To technique in
lungs and chest
limits. relaxing promote pursed-lip
OBJECTIVE cavity. The
- Patient will environment adequate breathing,
CUES body produces
achieve rest abdominal
pleural fluid in
maximum periods to breathing
small amounts
 Shortnes lung limit and
to lubricate the
s of expansion fatigue relaxation
surfaces of the
breath with techniques
 upon pleura. This is adequate d. Elevate - To - Patient
exertion the thin tissue ventilation. patient head promote reported
 Crepitant that lines the - Patient will lung feeling
moist chest cavity and report expansion rested
rales and surrounds the feeling - Patient is
wheezing lungs. Pleural rested e. Teach patient - These feeling
 Initial effusion is an - Patient on pursed-lip activities comfortable
V/S: abnormal, demonstrat breathing, allow when
T – 37.0 excessive ed correct abdominal patient breathing.
P – 100 collection of this technique breathing and participate
bpm fluid. There are in pursed- relaxation in GOAL MET
R – 20 two types of lip technique maintainin
cpm pleural effusion: breathing, g health
BP – Exudative abdominal status and
174/121 effusion and breathing ventilation
mmHg Transudative and
02 Sat – pleural effusion. relaxation DEPENDENT: DEPENDENT:
96% techniques
 CXR: Transudative . a. Administer a. Suppleme
Right pleural effusion supplemental ntation of
Pleural is caused by oxygen as oxygen
Effusion fluid leaking into prescribed helps to
the pleural improve
space. This breathing
is from pattern
increased and relieve
pressure in the respiratory
blood vessels distress
or a low blood
protein b. Administer b. For the
count. Congesti prescribed pharmacol
ve Heart medications ogical
failure is the as ordered managem
most common ent of the
cause. patient’s
condition

COLLABORATIVE: COLLABORATIV
REFERENCE:
E:
 U.S. National a. Coordinate a. Physiother
Library of with the apy and
Medicine. (n.d.). respiratory fluid
Pleural effusion: therapist and drainage
Medlineplus provide helps
medical assistance on patient to
encyclopedia. ordered chest improve
MedlinePlus. physiotherapy lung
https://medlinep procedure function
lus.gov/ency/art and
icle/000086.htm strengthen
. breathing
muscles
and
improve
respiration

b. Coordinate b. Poor diet

with a especially
dietician consuming
about the too much
proper diet if salt makes
the px may be edema
required to worse.
limit sodium Sodium
intake that restrictions
can be a can be
factor for effective to
excess fluids manage it.
in the body
causing
edema.
MELLY B. ALIMAN, SN.

FOCUS DATA ACTION RESPONSE

Ineffective breathing pattern Subjective: 1. Established rapport After 1-2 hours of nursing
r/t right pleural effusion 2. Monitored and intervention the patient’s
 secondary to Congestive “Katong bag-o palang wala pa
Heart Failure ko na stroke, gasugod na
lisdan ko ginhawa usahay.
Pero after na ato, ga sige na
atake. Lisdan nako ginhawa”,
as verbalized by the patient
Objectives:
 Shortness of breath
upon exertion
 Crepitate moist rales
and wheezing
 Initial V/S:
T – 37.0
P – 100 bpm
R – 20 cpm
BP – 174/121 mmHg
2 at – 96%
 CXR: Right Pleural
Effusion
Melly B. Aliman, SN
recorded vital signs comfort increases as evidenced
3. Assessed breath by:
sounds, respiratory
rate, depth and
rhythm - Patient’s vital signs is
4. Elevated the head of within established limits.
the patient - Patient demonstrated
5. Provided relaxing correct technique in
environment pursed-lip breathing,
6. Assisted in using abdominal breathing and
relaxation technique relaxation techniques
7. Administered - Patient reported feeling
prescribed rested
medications - Patient is feeling
8. Encouraged comfortable when
adequate rest periods breathing.
between activities
GOAL MET