TARLAC STATE UNIVERSITY

COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines

NURSING CARE PLAN

Name Pearl Angeli M. Sabal Area

Year Level Level II RLE Group Group 03 Inclusive dates of Rotation
Name of Patient Baby Carla Age Gender Female
Date Admitted 02/05/2022 Medical Diagnosis Respiratory Distress Syndrome

ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS

Subjective Data: Ineffective Breathing After 1 to 2 hours of Independent: Independent: After 1 to 2 hours of
• N/A Pattern related to proper nursing proper nursing
Objective Data: Decreased Lung intervention, the client 1. Place the client’s 1. To avoid forward intervention, the client
• AOG - 36 Surfactant will be able to neck and head in and backward was able to maintain
Weeks maintain an effective a proper position. bending of the an effective breathing
• Weight – 1.8 breathing pattern neck that might pattern
kilograms cause airway AEB
Vital Signs blockage • Relaxed
• BT – 36.2 breathing
• HR – 170 2. Check for any 2. To prevent the • Absence of
bpm obstruction in the blockage of nasal flaring
• RR – 80 bpm client’s airway secretions in the • RR- 40 bpm
• BP – 40/50 (secretions and client’s airway • HR – 130
mmHg mucus) and helping the bpm
Physical provide proper newborn to • BP – 100/50
Examination suctioning using acquire effective mmHg
proper tubing breathing
• Poor sucking
reflex Remarks:
• Nasal Flaring • Goal is met
3. Provide proper 3. To provide
oxygenation with enough
a flow rate of 1 oxygenation that
 liter/minute via might help the
nasal cannula newborn to
acquire effective
breathing

4. Provide tactile 4. To help stimulate

stimulation by spontaneous
rubbing gently breathing in case
the soles of the of periods of
feet or chest wall apnea
of the client

Dependent: Dependent:

1. Administer 1. To aid in
medications effective lung
(bronchodilators, function
synthetic
surfactant) as
ordered by the
primary care
physician

2. Place the client in 2. To help in

a Continuous providing
Positive Airway enough oxygen
Pressure (CPAP) and keep an
with the effective
recommended breathing pattern
flow rate as
ordered by the
primary care
physician

Collaborative: Collaborative:

1. Refer to a 1. To accurately
Pulmonologist assess the
 or Primary client and
Care provide
Physician further
intervention
as needed

Name of Student Pearl Angeli M. Sabal Date Submitted 02/05/2022

Year, Section, and Group BSN 2B – Group 4 Clinical Instructor Rowena B. Lamorena