Taibah University

Al-Madinah Al-Munawara ‫جامعة طيبة‬

Kingdom of Saudi Arabia ‫المدينة المنورة‬
College of Nursing ‫المملكة العربية السعودية‬
Medical Surgical Department ‫كلية التمريض‬
‫قسم الجراحة الطبية‬

Nursing Care Plan (NCP) (1) According priority

Patient Name:__ __________________________ Unit:__ ___ ___________ Room/Bed No.:________ Medical

Diagnosis:_________________________
Nursing Patient-Centered Nursing Diagnosis
Evaluation Rationale Assessment
interventions Goals
After 6 hours of 1- Useful in Independent: impaired Gas Subjective Cues:
nursing evaluating the Exchange r/t over
1- Assess and NON
intervention,Client degree of respiratory After 6 hours of nursing intervention, production of
Was able to maintain distress or chronicity record respiratory Client Will be able to maintain oxygen ketonbodies
oxygen level and of the disease rate, depth. Note the level and effective breathing pattern evidence by
effective breathing process. use of accessory within normal range .
pattern Within muscles, pursed-lip Dyspnea, SOB , fruity
Acceptable manner . 2- Cyanosis may be breathing, inability breath .
peripheral (noted in to speak or
nail beds) or central converse. Objective Cues:
Goal is partially
met (noted around lips/or PH = 7.20
earlobes). Duskiness 2- Assess and PCo2 = 31 PH = 7.20
and central cyanosis routinely monitor HCo3 = 12 PCo2 = 31
indicate advanced skin and mucous SaO2 =85 % HCo3 = 12
hypoxemia membrane color.
Dyspnea , SOB ,
Fruity breath .
3- Pulse oximetry 3- Monitor O2
reading of 87% saturation and titrate
below may indicate oxygen to maintain
the need for oxygen Sp02 between 88%
administration while to 92%
a pulse oximetry
reading of 92% or
 Taibah University
Al-Madinah Al-Munawara ‫جامعة طيبة‬
Kingdom of Saudi Arabia ‫المدينة المنورة‬
College of Nursing ‫المملكة العربية السعودية‬
Medical Surgical Department ‫كلية التمريض‬
‫قسم الجراحة الطبية‬

Nursing Patient-Centered Nursing Diagnosis

Evaluation Rationale Assessment
interventions Goals
higher may require
oxygen titration. 4- Elevate head of
bed/position client
appropriately,
4- to maintain provide
airway. airway adjuncts and
suction, as indicated

5- Breath sounds 5- Auscultate breath

may be faint because sounds, noting areas
of decreased airflow of decreased airflow
or areas of and adventitious
consolidation sounds

6- Restlessness,
agitation, and 6- Monitor changes
anxiety are common in the level of
manifestations of consciousness and
hypoxia. mental status.

7- Helps limit
oxygen
needs/consumption
7- Encourage
adequate rest and
limit activities to
within client
8-to treat underlying tolerance. Promote
conditions. calm/restful
environment.
 Taibah University
Al-Madinah Al-Munawara ‫جامعة طيبة‬
Kingdom of Saudi Arabia ‫المدينة المنورة‬
College of Nursing ‫المملكة العربية السعودية‬
Medical Surgical Department ‫كلية التمريض‬
‫قسم الجراحة الطبية‬

Nursing Patient-Centered Nursing Diagnosis

Evaluation Rationale Assessment
interventions Goals
9- to improve :
respiratory
function/oxygen- Dependent:
carrying capacity.
8-Administer
medications, as
indicated (e.g.,
inhaled)
Collaborative:
9-Assist with
procedures as
individually indicated