NURSING CARE PLAN

Patient’s Name: FATIMA AL MANSOORI Thiqa No.: Gender: FEMALE

ALZHEIMER’S DSE.,DIABETES MELLITUS, CKD STAGE 3,CHRONIC ANEMIA,CHRONIC
Initial Diagnosis: MRN: 066
RESPIRATORY FAILURE,HYPERTENSION

ASSESSMENT NURSING DIAGNOSIS GOAL/PLAN OF CARE NURSING INTERVENTIONS RATIONALE EVALUATION

Objective: Impaired swallowing After 24hrs of nursing Suction saliva and secretions as often To prevent After 24hours nursing
-excessive salivation interventions patient should be: as necessary. accumulation of interventions, goal met.
-inability to swallow excessive saliva Clear breath sound,
-on NGT feeding -free of signs of aspiration and   and prevent the resonant percussion over
the risk of aspiration is patient from the lungs are noted.
decreased.. choking. There is absence of
cough and the vital signs
-maintains a patent airway with Proper positioning of the patient To prevent are within normal limits.
clear lungs upon auscultation aspiration
through correct
positioning

Elevate the head of bed to 30 to 45 Keeping patient’s

degrees while feeding the patient and head elevated
for 30 to 45 minutes afterward if helps keep food
feeding is intermittent. Turn off the in stomach and
feeding before lowering the head of decreases
bed. Patients with continuous feedings incidence of
should be in an upright position. aspiration

Stop continual feeding temporarily When turning or

when turning or moving patient. moving a patient,
it is difficult to
keep the head
elevated to
prevent
regurgitation and
possible
aspiration.
 Provide oral care Oral care reduces
the risk for
ventilator-
associated
pneumonia by
decreasing the
number of
microorganisms
in aspirated
oropharyngeal
secretions.

Educate the patient and family the need Upright

for proper positioning. positioning
decreases the risk
for aspiration.

ASSESSMENT NURSING DIAGNOSIS GOAL/PLAN OF CARE NURSING INTERVENTIONS RATIONALE EVALUATION

Subjective: NONE Decreased cardiac output Short term goal:
related to hypertension
Objective: after 6hrs of nursing intervention
-consistent elevation of the patient will demonstrate
blood pressure adequate cardiac output as
-increased peripheral evidenced by blood pressure and
vascular resistance pulse rate and rhythm within
normal parameters for patient
Long term goal:
After 1 month of nursing
intervention the client will:
-maintain adequate cardiac output Note edema
and remains free of side effects
from the medications used to
achieve adequate cardiac output
Monitor BP hourly after giving
antihypertensive medications.
Measure in both arms/thighs 3–5
min apart while patient is at rest,
Use correct cuff size and accurate
technique.
Observe skin color, temperature,
capillary refill time and
diaphoresis.
Auscultate heart tones and breath
sounds.
Promote bedrest, schedule periods Reduces physical stress
of uninterrupted rest; assist patient and tension that affect
with self-care activities as needed. blood pressure and the
Changes in BP may after 6hrs of nursing
indicate changes in intervention the patient
patient status requiring had no elevation in blood
prompt attention. pressure above normal
limits and maintain blood
pressure within
acceptable limits.
Peripheral Goal was met.
vasoconstriction may
result in pale, cool, Long term goal:
clammy skin, with
prolonged capillary After 1 month of nursing
refill time. intervention the client
will:
May indicate heart -maintain adequate
failure, renal or cardiac output and
vascular impairment remains free of side
effects from the
S4 heart sound is medications used to
common in severely achieve adequate cardiac
hypertensive patients output
because of the presence -Goals met
of atrial hypertrophy .
(increased atrial
volume/pressure).
Development of
s3 indicates ventricular
hypertrophy and
impaired functioning.
Presence of crackles,
wheezes may indicate
pulmonary congestion
secondary to
developing or chronic
heart failure.
course of hypertension.
 Provide comfort measures, e.g., Decreases discomfort
back and neck massage, elevation and may reduce
of head. sympathetic
stimulation.

Administer medications as per To reduce BP.

physicians order.

ASSESSMENT NURSING DIAGNOSIS GOAL/PLAN OF CARE NURSING INTERVENTIONS RATIONALE EVALUATION

Objectives: Risk for impaired skin integrity After 8 hrs of nursing Assess the overall condition of the A healthy skin should fter 8 hrs of nursing
interventions patient will skin. have good turgor (an interventions patient will
-immobility have good skin turgor,dry and indication of moisture), have good skin
-dry skin free from impairment like Patients with advanced turgor,dry and free from
-fecal and urinary rashes,abrasions or age are at high-risk risk impairment like
incontinence excoriation. for skin impairment rashes,abrasions or
because skin is less excoriation.
elastic, has less -Goal met
moisture, and has
thinning of the
epidermis.

Check on bony prominences such Specific areas where

as the sacrum, trochanters,
scapulae, elbows, heels, inner and
outer malleolus, inner and outer
knees, back of head).
skin is stretched tautly
are at higher risk for
breakdown because the
possibility of ischemia
to skin is high as a
result of compression of
skin capillaries between
a hard surface (e.g.,
mattressor wheelchair)
and the bone. 

Use an objective tool for pressure Assessment should be

ulcer risk assessment ( Braden or every 24 to 48 hours or
Norton scale) sooner if the patient’s
condition changes.

Change diaper every 2 hours or as Stool may contain

necessary if already soaked.
enzymes that cause skin
breakdown. The urea
in urine turns into
ammonia within
minutes and is caustic
to the skin. Use of
diapers and
incontinence pads
hastens skin
 breakdown.

Use of lifting devices like trapeze Common causes

or bed linen to move the patient in of impaired skin
bed. integrity is friction
which involves rubbing
heels or elbows toward
bed linen and moving
the patient up in bed
without the use of a lift
sheet. A common cause
of shear is elevating the
head of the patient’s
bed: the body’s weight
is shifted downward
onto the patient’s
sacrum.

Implementation of a turning Turning every 2 hours

schedule, restricting time in one
position to 2 hours or less, if the
patient is restricted to bed.
is the key to prevent
breakdown. Head of
bed should be kept at
30 degrees or less to
avoid sliding down on
bed.

Prepared By: MA ELOIDA PRIMA V. ZULUETA GN10685

Date: MARCH 17,2022