NURSING CARE PLAN

Name of Client : M. G. A.
Medical Diagnosis/Impression: Bronchopneumonia

Date Cues Nursing Diagnosis Scientific Basis Goal Nursing Intervention Rationale Date Evaluation

01/23/18 Subjective: Ineffective airway Because of constant After 30 minutes Independent: 01/23/18 After 30 minutes of
clearance related to irritation, the mucus of nurse-client 1. Assess respiratory - diminish breath sounds nurse-client
“Sige man lang ni ang thick, green-yellow secreting glands and interaction, the functions e.g. breath may reflect atelectasis. interaction, the
akong ubo, maglisod pa sounds, rate, rhythm, Ronchi, wheezes
secretions. gobbler cells increased client will be able client have
gyud ko ug ginhawa” as and depth, ability to indicate accumulation
in number, ciliary to maintain a expectorate mucus or achieved a patent
verbalized by the client. of secretions. Inability to
function is reduced, patent airway as cough effectively, clear airway that may airway as
and more mucus is evidenced by: character/amount of lead to the use of evidenced by:
produced. The sputum, presence of accessory muscles &
bronchial walls a. decreased hypothesis. increased work of a. absence of
Objective: RR from 36 dyspnea
become thickened the breathing.
to 25 bpm. 2. Place in semi/high - position helps maximize b. RR -30bpm
. nasal flaring noted bronchial lumen is b. absence of c. decrease cough
Fowler’s position. lung expansion &
narrowed and mucus nasal flaring decrease respiratory
. dyspnea noted may plug the airway. when effort.
Accumulated breathing 3. Assist with coughing & - prevent obstruction
. RR – 36bpm secretions in the deep breathing exercises.
bronchioles interfere 4. Clear secretions from - suctioning maybe
. productive cough
with effective airway mouth & trachea, suction necessary if the client
clearance. as necessary. cant expectorate
. diaphoresis
5. Maintain fluid intake of @ - more fluid intake helps to
least 2,500ml/day unless thin secretions making it
contraindicated easier to clear
Reference:
Collaborative:
Medical-Surgical 1. Ventolin 2.5mg 1 tab p.o. - increase lumen size of
Nursing by Smeltzer TID the tracheobronchial tree
thus decreasing
and Bare, Vol 1. p 451 resistance of air flow
2. Carbocisteine 500mg 1 - reduce the thickness of
cap p.o. TID pulmonary secretions to
facilitate clearance
 NURSING CARE PLAN

Name of Client : R. G. T.
Medical Diagnosis/Impression: Diabetes Mellitus

Date Cues Nursing Diagnosis Scientific Basis Goal Nursing Intervention Rationale Date Evaluation

11/16/18 Subjective:
“Hindi ko na magawang
maligo at mag ayos pa ng
katawan dahil tinamad ako”
as verbalized by the client.
Objective:
. discomfort
. unpleasant odor
. unfixed hair
. dry skin
. presence of dandruffs
Self – care deficit Bathing removes After 1 hour of Independent: 11/16/18 After 1 hour of
related to lack of accumulated oil, nurse-client 1. Establish rapport . - to establish trust and nurse-client
motivation in perspiration, dead skin interaction, the cooperation interaction, the
performing good cells, and some client will be able 2. Monitor the vital signs. - to obtain the baseline client was able to
hygiene. bacteria. In addition to to perform good data perform good
cleaning the skin, hygiene and she 3. Provide health teaching - to provide adequate hygiene and she
bathing also stimulates will cooperate in regarding the proper way knowledge was able to
circulation. A warm or the procedure of of effective oral hygiene. cooperate in the
hot bath dilates bathing and procedure of
superficial arterioles, proper grooming. 4. Explain the procedure of - to provide correct pattern bathing and proper
bringing more blood proper bathing and hair of performing the grooming.
and nourishment to the brushing. procedure.
skin.
Bathing also 5. Guide and support the - to avoid accident and for
produces a sense of client and let her perform the client to practice the
well-being. It is the procedure. procedure
refreshing and relaxing
and frequently
6. Encourage her to take a - to inform the client of her
improves morale,
bathe everyday and be responsibility as an
appearance, and self-
responsible mother to her individual.
respect.
physical appearance.

7. Explain the essence of the - to help protect her baby

mother as a clean and a while in contact with her
presentable mother to her
baby.
Reference:
Fundamentals of 8. Inform the relatives to help - to have cooperation and
Nursing by Kozier and the client in doing her duty guidance coming from
Erbs, Vol 2. p 700 everyday regarding her the relatives
proper hygiene.