DAVAO DOCTORS COLLEGE

General Malvar St., Davao City

Nursing Program

NURSING CARE PLAN

Name of Patient: Mrs. XYZ Date of Admission: Jan 14, 2022 Room: 211 - A
Age: 75 yo Sex: Female Civil Status: Married Chief Complaint: Difficulty of breathing
Religion: Roman Catholic Attending Physician: Dr. J. Orcasitas

GOALS/ NURSING
PROBLEM SCIENTIFIC BASIS RATIONALE EVALUATION
OBJECTIVES INTERVENTIO
CRITERIA NS
Jan. 14, 2022 SMART INDEPENDENT Goal met
@ 7am Ineffective airway DEPENDENT Goal Partially Met
clearance R/t At the end of my 12 hours COLLABORATIVE Goal not met
Subjective : shift, patient will have
“ Mam, Lisod man
inflammation of airways effective airway clearance Assess vital signs every 4 Assessing Vital signs will Jan. 14, 2022 @ 6pm
ko ginhawa.,, secondary to COPD as evidence by patient hours. help monitor Pt’s
tabangi ko” As evidence by Patient having respiratory status.
having wheezing on Clear breath sounds on Goal Met as evidence by
bilateral upper lobes bilateral upper lobes during patient having clear breath
during expiration; o2 sat expiration, o2 sat of 92 % sounds on bilateral upper
- 95%. And respiration of Monitor Respiration and Monitoring Respiration lobes; O2sat of 96% and
of 90% and respiration
16-20 breaths per minute. Breath sounds every 4 and breath sounds is RR of 20 breaths per
Objective of 26 breaths per hours indicative of distress or minute.
VS minute. accumulation fluids.
BP – 130/90 Goal Partially Met as
RR – 27 Scientific Basis: evidence by patient still
O2sat – 90% (from MS Nsg. Book) Breathing treatment is a having wheezing on
Temp – 36.1 Administering breathing bronchodilator which bilateral upper lobes during
HR – 100 treatments (insert meds opens up the airways. expiration; O2sat of 96%
Wheezing on here) every 4 hours or as and RR of 20 breaths per
bilateral upper ordered by the Physician. minute.
lobes during
expiration. Goal not Met as evidence
by patient still having
Xray result: wheezing on bilateral
 Bilateral upper lobes during
Pneumonia expiration; O2sat of 90%
and RR of 28 breaths per
minute.

REFERENCES:

Berman, A., Snyder, S. &

Frandsen G. (2016). Study guide
for Kozier & Erb’s fundamentals
of nursing: Concepts, process,
and practice (10th ed.). Pearson
Education, Inc. https://b-
ok.asia/book/3640555/be18df

BBN/DTS/2020 NAME OF STUDENT