University of Southern Mindanao

College of Health Sciences

Department of Nursing

NURSING CARE PLAN

Name of Patient: ______________________________________Age: ______ Sex: _____ Room: ________Date:
__________________________
Admitting Diagnosis: _________________________________Attending Physician: _________________________Diet: __________________

Assessment Nursing Planning Intervention Rationale Evaluation

Diagnosis
Subjective: 1. Establish rapport. 1. To gain patient's trust.
 "Sumisikip Risk For Short term goal: 2. Monitor vital signs. 2. To have baseline data Short term goal:
daw po yung Decreased After 8hrs of 3. Assess client's blood 3. Mechanical ventilation can Goal met
dibdib nya" Cardiac nursing care, pressure and heart rate. produce a decreased venous After 8hrs of nursing
as stated by Output related client will return to the heart, resulting in care, client maintained
the watcher. to Positive- maintain decreased BP, compensatory adequate cardiac output
Objective: Pressure adequate increased heart rate, and and HR to 60 to 100
 BP-130/90 Ventilation cardiac output decreased cardiac output. This beats per minute with
mmHg and HR to 60 to 4. Assess the client’s level may happen abruptly with regular rhythm.
100 beats per of consciousness. ventilator changes: rate, tidal
 HR- 108
minute with volume, or positive-pressure Long term goal:
bpm
regular rhythm. ventilation. Goal met
 Altered
Long term goal: 4. The level of consciousness will Client had a normal
myocardial
Client will have 5. Assess the capillary decrease if cardiac output is cardiac output and report
contractility
normal cardiac refill, skin temperature, severely compromised. Therefore no chest pain.
 Extra heart output and and peripheral pulses. close monitoring during ventilator
sounds report no chest changes is imperative.
 Decreased pain.
urine output 5. Pulses are weak with reduced
 Diminished stroke volume and cardiac output.
peripheral 6. Monitor for Capillary refill is slow with reduced
 pulses dysrhythmias. cardiac output. Cold, pale, clammy
 Cool, ashy skin is secondary to compensatory
skin; 7. Monitor fluid balance sympathetic nervous system
diaphoresis and urine output. stimulation and associated with low
 Wheezes cardiac output and oxygen
 Tachypnea desaturation.
6. Cardiac dysrhythmias may result
from the low perfusion state,
8. Notify the physician acidosis, or hypoxia.
immediately of signs of a 7. Optimal hydration status is
decrease in cardiac needed to maintain effective
output, and anticipate circulating blood volume and
possible ventilator setting counteract the ventilatory effects
changes. on cardiac output. With positive
pressure ventilation, pressure from
9. Maintain an optimal fluid the diaphragm decreases blood
balance. flow to the kidneys and could result
in a drop in urine output.
8. Vigilant monitoring reduces the
risk for complications. Hypotension
and decreased cardiac output may
10. Administer be related to positive-pressure
medications as ordered ventilator itself or use of positive
(diuretics, inotropic end-expiratory pressure (PEEP)
agents). mode.

9. Volume therapy may be

required to maintain adequate
filling pressures and optimize
cardiac output. However, if PADP
and/or pulmonary capillary wedge
pressure rises and cardiac output
remains low, fluid restriction may
 be necessary.
10. Diuretics may be useful to
maintain fluid balance if fluid
retention is a problem. Inotropic
agents may be useful to increase
cardiac output.

NURSING CARE PLAN

Name of Patient: ______________________________________________________ Age: _________ Sex: ______ Room:

____________Date:________________
Admitting Diagnosis: ___________________________________________________ Attending physician: _________________________Diet:
________________
 Assessment Nursing Planning Intervention Rationale Eva
Diagnosis
O:Vital signs: Risk for trauma The patient will remain free of 1. Assess client’s temperature. 1. Fever may be a Goal me
T: 37.3°C and infection infection, as evidenced by normal 2. Assess skin integrity under tracheal manifestation of an
PR: 79 bpm related to temperature, absence of purulent ties. infection or inflammatory The pati
RR: 17 endotracheal drainage around the stoma, and 3. Observe the stoma for erythema, color, process. from an
BP: 110/70 intubation or clear breath sounds. exudates, and crusting lesions. If 2. This is a common site for symptom
tracheostomy present, culture the stoma and notify infection and skin infection
the physician. breakdown. manifest
4. Monitor white blood cell (WBC) count. 3. The buildup of mucus and absence
5. Maintain an inflated tracheostomy cuff the rubbing of the
at the lowest pressure possible to tracheostomy tube can
maintain an adequate seal for irritate the skin and serve
ventilation. as a site for infection.
6. Keep a tracheal obturator taped at the Culture and sensitivity
head of the bed for emergency use. reports guide the antibiotic
7. Keep a spare tracheostomy tube of selection.
same size and brand at the bedside. 4. An increasing WBC
8. Do not allow secretions to pool around indicates the body’s effort
the stoma. Suction the area, or wipe to combat pathogen.
with aseptic technique. Keep the skin 5. An inflated cuff protects the
under the tracheostomy ties and back airway and is required for
 of the neck clean and dry. mechanical ventilation.
9. Provide stoma care Cuffs should be kept at the
10. If signs of infection are present, apply lowest pressure to prevent
an antifungal or antibacterial tracheal erosion. Clients
medication, as prescribed. are not able to vocalize
while the cuff is properly
inflated.
6. The tracheal obturator is
used to reinsert the
tracheostomy.
7. Being prepared for an
emergency helps prevent
future complications.
8. These steps keep the
stoma clean and dry. The
back of the neck should be
checked carefully in
bedridden clients because
secretions tend to flow to
the back of the neck.
Clean, dry skin helps
prevent skin irritation.
 9. Frequent stoma care is
required for postoperative
clients. Care for clients with
long-term stoma placement
is based on need.
10. These agents are either
toxic to the pathogen or
retard its growth.
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