NURSING CARE PLAN

Deficient Knowledge related to unfamiliarity with information as evidenced by development of

preventable complications
In partial fulfillment of the requirements for the subject
NCM 112 – CARE OF CLIENTS WITH PROBLEMS IN OXYGENATION, FLU

Presented By:
MANELA, Jimuel Brian M.
BSN 305

Submitted To:

Of October, 2021
 I. PATIENT PROFILE

Cues Nursing Analysis (with Goals and Implementation Rationale valuation

 Diagnosis reference) Objectives
Subjective Deficient SCIENTIFIC Short-Term Goal: Short-Term
Data: ANALYSIS: After 3 hours of nursing Goal:
Knowledge
intervention with the ✓Met /
“Ano po ba itong related to The U.S. Department client, the client will be _Partially Met
mga pinag of Health and Human able to participate in the / _NOT Met
gagawa saakin unfamiliarity Services (HHS) learning process. a.
na procedure? with defines health literacy Effectiveness
Mamatay na po as “the degree to
ba ako?” as information which individuals the client
verbalized by the as evidenced have the capacity to participated in the
patient. obtain, process, and learning process.
by understand basic
Objective Data:
development health information Objectives: Objectives:
needed to make Nursing care plans are
(+) History of of preventable 1. Affective Independent ✓Met /
appropriate health a vital part of the
Past Illness
complications. decisions.”1, The client will The nurse will examine nursing process. They _Partially Met
(+) Irregular 2Adequate health participate during the the patient's and SO's provide a centralized
/ _NOT Met
breathing pattern literacy may include health teaching. knowledge, abilities, document of the
being able to read and and willingness to learn. patient's condition,
(+) Guarding comprehend essential diagnosis, the nursing a.
behaviour health-related team's goals for that Effectiveness
materials (e.g., patient, and measure
(+) Restlessness prescription bottles, of the patient's The client
(+) Facial mask appointment slips, progress. Nursing care participated
of pain. etc.).3, 4 Adequate plans are structured to during the health
health literacy may capture all the teaching.
increase a person’s important information
capacity to take for the nursing team in
V/S: responsibility for their one place. Because
health and their they centralize this
BP: 120/80 family’s health.5, 6 information and
However, health updates, they ensure
PR: 94
literacy is not just the that everything
RR: 20 result of individual important is
capacities but also the documented and
T: 37 health-literacy related available to all team
demands and members. This also
complexities of the makes patient
health care system. education easier, since
all nursing staff
SITUATIONAL members know and
ANALYSIS: can reinforce what the
patient needs to learn.
Because the patient is
(Nursing care plans
ignorant, she may not
explained.
understand
NurseJournal. 2021,
prescription labels and
October 12).
treatments that was
given to her. Independent

Risk factors, dietary and It focuses on

2. Cognitive ✓Met /
exercise limitations, improving daily
The client will identify medications, and function and reducing _Partially Met
the risk factors, symptoms requiring cardiovascular risk
limitations and prompt medical factors. Cardiac / _NOT Met
medications of attention will all be rehabilitation includes
interventions aimed at a.
dysrhythmia. reinforced by the nurse.
lowering blood
pressure and
 improving lipid and Effectiveness
diabetes mellitus
control, with tobacco The client
cessation, behavioral identified the risk
counseling, and factors,
graded physical limitations and
activity. medications of
(Servey, J. T., & dysrhythmia.
Stephens, M. B. 2016,
July 1).

Independent

3. Cognitive The nurse will explain It encourage patient

and reinforce specific participation in
The client will be able to dysrhythmia problem decisions about their ✓Met /
verbalize understanding and therapeutic care and help patients
of causes of measures to patient and retain important _Partially Met
dysrhythmia, methods of SO. information
preventing the (Levit, L. 2013, / _NOT Met
worsening of December 27). a.
dysrhythmia, and
comfort measures to Effectiveness
employ.
The client
verbalized
understanding of
causes of
dysrhythmia,
methods of
 preventing the
worsening of
dysrhythmia, and
comfort measures
Independent to employ.
It improves the
The nurse will advise muscles' ability to pull
4. Psychomotor the client to adopt a oxygen out of the
regular fitness regimen blood, reducing the
The client will regularly while staying away from
exercise, avoids need for the heart to ✓Met /
overexertion. Identify pump more blood to
overexertion. Identify symptoms that require the muscles. Reduces _Partially Met
signs and symptoms quick action, such as
requiring immediate stress hormones that
dizziness, / _NOT Met
cessation of activities: can put an extra
lightheadedness, burden on the heart.
dizziness, dyspnea, and chest pain. a.
lightheadedness, Works like a beta
dyspnea, chest pain. blocker to slow the Effectiveness
heart rate and lower
blood pressure. The client
(Exercise and the regularly
heart. Johns Hopkins exercise, avoided
Medicine. n.d.) overexertion.
Identified signs
and symptoms
requiring
immediate
cessation of
activities:
dizziness,
lightheadedness,
 Independent The potassium-sparing dyspnea, chest
diuretics used for pain.
5. Cognitive Individual dietary needs treating HF are the
and limits, such as aldosterone receptor
The client will create a
potassium and caffeine, antagonists
nutritional plan to ✓Met /
will be discussed with spironolactone and
prevent the disease from
the nurse. eplerenone. They act _Partially Met
worsening.
at the cortical
collecting duct, in / _NOT Met
particular by reducing
a.
the absorption of
sodium and water and Effectiveness
increasing the
excretion of hydrogen The client created
ions and potassium, a nutritional plan
and their action is and prevented the
mediated by the disease from
antagonism of the worsening.
actions of mineral
corticoids.
(Casu, G., & Merella,
P. 2015, July)
References:

Nursing care plans explained. NurseJournal. (2021, October 12). Retrieved October 19, 2021, from
https://nursejournal.org/articles/nursing-care-plans-explained/.

Servey, J. T., & Stephens, M. B. (2016, July 1). Cardiac rehabilitation: Improving function and reducing risk. American Family
Physician. Retrieved October 19, 2021, from https://www.aafp.org/afp/2016/0701/p37.html.

Levit, L. (2013, December 27). Patient-centered communication and shared decision making. Delivering High-Quality Cancer Care:
Charting a New Course for a System in Crisis. Retrieved October 19, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK202146/.

Casu, G., & Merella, P. (2015, July). Diuretic therapy in heart failure - current approaches. European cardiology. Retrieved October
19, 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6159465/.
Exercise and the heart. Johns Hopkins Medicine. (n.d.). Retrieved October 19, 2021, from
https://www.hopkinsmedicine.org/health/wellness-and-prevention/exercise-and-the-heart#:~:text=Improves%20the
%20muscles'%20ability%20to,rate%20and%20lower%20blood%20pressure.