Saint Paul University Philippines

Tuguegarao City, Cagayan 3500

School of Nursing and Allied Health Sciences
COLLEGE OF NURSING
Center of Excellence for Nursing
PAASCU LEVEL IV Accredited
First Semester, AY. 2021–2022

NCM 109- CARE OF MOTHER, CHILD AND ADOLESCENT (WELL CLIENT)

PBL 4 NURSING CARE PLAN 1

ASSESSMENT/CUES NURSING BACKGROUND PLANNING NURSING RATIONALE EVALUATION

(Differentiate DIAGNOSIS KNOWLEDGE (Include Long and INTERVENTIONS (With scientific (State whether met,
Objective from (Actual or Short-Term Goals (At least 4 and evidence as partially met or
Subjective Data) Potential plus at least 3 include only the needed) unmet and the
with outcomes) most appropriate supporting
complete for client’s) outcomes)
parts)

Subjective data: Ineffective Ineffective NOC: Respiratory NIC: Airway NIC: Airway THE GOAL WAS:
Breathing breathing Status: Ventilation; Management; Management; Met
- Mrs. SC stated Pattern as patterns are Vital Signs Respiratory Respiratory Partially Met
that Ivana had evidenced considered a Monitoring Monitoring Not met
colds for by severe state in which
almost a week. difficulty in the rate, depth,
- Denied fever, breathing, timing, rhythm, Short-Term Goal: Short-Term Goal:
trauma and severe or After 5 hours of After 5 hours of
ingestion of retractions chest/abdominal nursing nursing
object but of the wall excursion interventions, the interventions, the
vomited once sternum and during patient will be able patient:
to previously wheezing. inspiration, to: a. Monitor a. Accurate - Manifested
ingested milk expiration, - Manifest breathing patterns monitoring leads diaphragmatic
formula. or both do not diaphragmatic (e.g., bradypnea, to early breathing pattern
- No history of maintain breathing pattern. tachypnea, identification and - Had a normal
previous optimum - Have a normal hyperventilation, treatment of breathing pattern.
hospitalization. ventilation for breathing pattern. Kussmaul impending
- No significant the individual. respirations, respiratory
 Saint Paul University Philippines
Tuguegarao City, Cagayan 3500
School of Nursing and Allied Health Sciences
COLLEGE OF NURSING
Center of Excellence for Nursing
PAASCU LEVEL IV Accredited
First Semester, AY. 2021–2022

NCM 109- CARE OF MOTHER, CHILD AND ADOLESCENT (WELL CLIENT)

history was When the Cheyne-Stokes failure. 
transported to breathing respirations, Long-Term Goal:
St. Paul pattern is Long-Term Goal: apneustic, Biot After 4 days of
Hospital ineffective, the After 4 days of respiration, ataxic nursing
Emergency body will likely nursing patterns). interventions, the
Room not get enough interventions, the patient:
oxygen to the patient will be able b. Reveals the - Maintained
Objective data: cells. to: b. Assess skin, nail presence of respiratory
Respiratory - Maintain beds, skin mucous hypoxemia rate within
- 12 months old failure may be respiratory membranes for causing cyanosis established
- Severe correlated with rate within pallor or cyanosis. from an uneven limits.
difficulty in variations in established distribution of - Demonstrated
breathing respiratory rate, limits. gases and blood maximum
- Nurse Sheila abdominal and - Demonstrates in the lungs, lung
noticed the thoracic patterns maximum alveolar expansion
child was (Wayne, 2021). lung hypoventilation with adequate
cyanotic. expansion caused by ventilation.
- Severe with adequate airway
retractions of ventilation. obstruction and
the sternum, absence of chest
wheezing, has wall movement.
decreased
intake and
lethargic c. Assist the c. These
- The ROD patient to a measures
ordered Ivana comfortable promote comfort,
for intubation position, such as chest expansion,
stat. by supporting and ventilation of
Vital signs: upper extremities basilar lung
fields.
 Saint Paul University Philippines
Tuguegarao City, Cagayan 3500
School of Nursing and Allied Health Sciences
COLLEGE OF NURSING
Center of Excellence for Nursing
PAASCU LEVEL IV Accredited
First Semester, AY. 2021–2022

NCM 109- CARE OF MOTHER, CHILD AND ADOLESCENT (WELL CLIENT)

with pillows,
- T- 37.2 providing an
- PR- 120 bpm overbed table with
- RR- 54 bpm  a pillow to lean on,
and elevating head
of bed. 
d. Oxygen
administration is
d. Administer a therapy to
oxygen as maintain
prescribed.  adequate tissue
oxygenation
while minimizing
cardiopulmonary
work.

e. Assistance
helps the patient
e. Provide by clearing the
respiratory airway and
assistance as promoting
needed.  oxygenation.

f. Indicated for
mild and
f. Provide tactile intermittent
stimulation by episodes of
apnea to
 Saint Paul University Philippines
Tuguegarao City, Cagayan 3500
School of Nursing and Allied Health Sciences
COLLEGE OF NURSING
Center of Excellence for Nursing
PAASCU LEVEL IV Accredited
First Semester, AY. 2021–2022

NCM 109- CARE OF MOTHER, CHILD AND ADOLESCENT (WELL CLIENT)

applying gentle rub stimulate
in the soles of feet spontaneous
or chest wall. breathing.

g. Vagal
g. Avoid prolonged stimulation may
suctioning; cause
discourage taking bradycardia,
rectal triggering apneic
temperatures and episodes.
tube feedings.