NURSING CARE PLAN

Patient: Amelita Pepito Age: 58,F

Diagnosis: SOB, Massive Pleural Effusion in Impending Tamponade, TB in origin, HCVD Diabetes Type II uncontrolled insulin-
requiring
Date
and Assessment Need Diagnosis Planning Interventions Evaluation
Time
August Objective: A Ineffective Within 3 hours span Independent Goal Met @ 12
28, - Endotracheal C Breathing of care, the patient 1. Assessed the patient’s PM
2021 Tube attached T Pattern related to will be able to RR, depth, and pattern,
(9AM) to Mechanical I massive pleural demonstrate effective including the use of After 3 hours and
Ventilator V effusion respiratory patterns. accessory muscles. (R: 30 minutes span
- Wheezing (+) I secondary to Changes in the of care, the patient
- Pallor (+) T tuberculosis as 1. Maintain effective respiratory rate and was able to
- Dyspnea (+) Y evidenced by low breathing pattern rhythm are early signs of demonstrate
- Slow Capillary oxygen saturation as evidenced by possible respiratory measures to the
Refill of 5 - of 89% and normal rate of distress.) effective
seconds increased respiratory and respiratory
- Secretions on E respiratory rate oxygen saturation 2. Evaluated skin color, pattern as
ET (+) X temperature, capillary evidenced by:
E Rationale: 2. Indicate through refill; observe central
R increased behavior and versus peripheral 1. Respiratory
Vital Signs: C respiratory and appearance of cyanosis. (R: Lack of rate of 20 and
BP = 130/90 I decreased oxygen feeling oxygen will cause oxygen
Temp = 36.3 °C S saturation are comfortable when blue/cyanosis coloring saturation of
RR = 25 bpm E present in patients breathing to the lips, tongue, and 95%
O2 sat = 89% with pleural fingers.) 2. Absence of
P effusion because 3. Demonstrate cyanosis,
A as increase fluid techniques that 3. Assessed ET and capillary refill
T builds up on the promote lung mechanical ventilator for of 2 seconds,
T pleura this makes expansion and any abnormalities on the temp of 36.7
E the lungs harder promote machine or the tubing. °C, BP of
R to expand and oxygenation (R: kinks or loose tubing 110/70 and
N makes it more in mechanical ventilator
difficult to breathe might prevent the absence of
that causes administration of wheezing
hyperventilation ordered oxygen on the 3. Suctioning of
that in turn would patient) excess
result in an secretions on
ineffective 4. Positioned patient’s head ET, positioned
breathing pattern 30-45° degrees or semi- the patient on
and decreased Co2 fowlers position (R: semi-fowlers
to 02 exchange in permits maximum lung and turned
the lungs causing excursion and chest while
decreased o2 expansion) providing
saturation. Salbu +
5. Performed suctioning on Ipratro
secretions on the through
endotracheal tube (R: nebulization
Facilitates adequate
clearance of blockage on
airway)

6. Turned the patients

every 2 hours. (R: Can
further break up and
move secretions to block
the airway and promote
circulation

Dependent
1. Adjusted settings of the
mechanical ventilator as
ordered (R: Promote
assistive oxygenation)

2. Provided respiratory
medication such as
Nebulize Salbutamol +
Ipratropium nebule as
ordered (R: Beta-
adrenergic agonist
medications relax airway
smooth muscles and
cause bronchodilation to
open-air passages)