UNIVERSITY of the ASSUMPTION Unisite Subdivision, Del Pilar, City of San Fernand, 2000 Pampangs, Philippines ‘COLLEGE OF NURSING & PHARMACY NURSING CARE PLAN Patient: Gender:_Male ‘Age: 43 years ald Medical Diagnosis: Date of Admission: _Aug.12, 2021 ‘CUES NURSING SCIENTIFIC PLANNING NURSING INTERVENTION RATIONALE EXPECTED OUTCOME DIAGNOSIS EXPLANATION Subjective: Tnefiective airway | Chronic exposure to | Short term goal: + Establish Rapport + Togain pationt'strust. | Short term gor *Nahihirapan akong —_ | dearance related to | lung irritants After 4-8 hours of After 4-8 hours of hhurnings,” 2s vorbalized | bronchospasm, J nursing intorventions | + Assesslevel of + This information is nursing interventions by the patient increased theclientwill be able | consciousness/cognitio essential for identifying | the client was able to: production of Destruction of wo: nand ability to protect potential for airway Objective ‘tenacious alveoli &elastic own airway. problems, providi + Maintained airway + Tackypnea secretions as fibers + Maintain airway baseline levelof care | patency, clear breath + Nasal faring evidenced by V patency, clear breath needed and influencing | sounds upon +Palelipsandoral | presence of sounds upon choice ofinterventions. | auscultation mucous membrane | wheozes Lung inflammation | auscuksation + Use of accessory J ‘+ Monitor respirations + Expectorated/clear muscle when + Expectorate/clear and breath sounds, + Indicative of respiratory. | secretions readily. breathing Airway obstruction | secretions readily. noting rate and sounds distress and/or + Cyanosis (eg, tachypnea, stridor, | accumulation of + With productive crackles, or wheezes) secretions. Long term goal: cough of thick, Hyperseeretion of | Long term goal: indicative of respiratory After 2-3 weeks of gelatinous sputum mucus After 2-3 weeks of distress and/or nursing interventions * Stocky build J nursinginterventions | accumulation of the client was able to: ‘ Wheezes upon thecientwill beable | secretions. auscultation on both Narrowing of to: Jungs during airways ; + Evaluate client's + Todetermine ability to | + Verbalized inspiration J +Verbalize cougl/gag reflex, protect own altway understanding of + Capillary refill< 3 understanding of amount and type of cause(s) and seconds Decreased lung cause(s) and secretions, and therapeutic elasticity therapeutic swallowing ability management regimen. managementsion premier university historic Cavite recognized for coxcellonco inthe dovolopment ‘of morally upight and glebally competive indvidvals, Republic of the Philippines. CAVITE STATE UNIVERSITY Don Severino De las Alas Campus Indang, Cavite College of Nursing WissiON Cavite state Universty shall provide excellent, equitable and relovant educational opportuntie in the arts, sdience and technolegy through ‘ual instucton and relevant ‘esearch and development activites. Itshall produce professional, skiled and moral upright inviduals for dobel competiivencss, NURSING CARE PLAN OF A CLIENT WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE ASSESSMENT eels ouTcomes PLANNING INTERVENTION RATIONALE EVALUATION ‘SUBJECTIVE The client wil Fave | SHORT TERM | INDEPENDENT The cient verbatzed, | Ineffective Airway | improved airway | GOALS 4.Monitor lung sounds every | 1.Respiratory monitoring is vital | After 8 hours of "Ang hirap umubo et’ | Clearance rit| clesranco as 4:8 hours and before and | because ronchi present in the | nursing interventions, nafhirapan pa ako | excessive sacrations | evidenced by | After 8 hours of | after coughing episodes | large airways may impair | the goal was MET as humminga.” and ineffective | effective coughing | nursing zirway patency evidenced by coughing techniques and a | interventions OBJECTIVE patent airway the client willbe | 2.Teach the cliant to maintain | 2.Hycration helps to thin the | Client's. verbalization Vital signs taken as able to adequate tydration by | secretions — which impairs | of relief, follows: drinking at least 8-10 glasses | eirway demonstrated 1-37.66 PR-57 RR-25 BP- 100/80 PHYSICAL EXAMINATION FINDINGS Dyspnea ‘Wheezing Productive cough * Barreled chest 4.Demonstrate behaviors to improve airway clearance 2Nerbalize improved coughing LONG TERM GOALS After 3 days of nursing interventions, the client will be able to: of fluid per day (if not contraindicated) 3.Teach and supervise Coughing techniques 4.Teach and _—_supervise spirometer techniques 10 times per hour while awake 5 Perform chest physiotherapy if needed and instruct the clint and SO in these techniques 2.Proper coughing techniques conserve energy, reduce airway collapse and lessen client frustration A.incentive spirometer isan ‘objective measure of depth of inhalation to promote lung ‘expansion 5.Chest physiotherapy techniques use forces of gravity and motion to facilitate secretion removal behaviors to improve airway clearance such as improved coughing technique and. improved ability to expectorate mucusNURSING CARE PLAN ASSESSMENT | DIAGNOSIS INFERENCE | PLANNING | INTERVENTION) RATIONALE EVALUATION Independent: Subjective: © Inoffecive | © Chronic After dhs. | * Assist pationt * Elevation of the Atter 4 hrs, airway obstructive (OF nursing to assume head of the bed Of nursing “Nahihirapan ako clearance pulmonary interventions, | position of facilitates intervention huminga” as related to disoase the client will | comfort, e.g., respiratory function “—\s, the client verbalized by the increased (COPD) isa demonstrate elevate head by use of gravity. was able to patient. production of disease behaviors to | of bed, demonstrate secretions. characterized improve encourage behaviors to Objective: by airtiow airway pationt to loan improve limitation that clearance. on overbed ainway + Use of isnot fully eg. cough table or sit on clearance, accessory reversible. Air | eftectvely the edge of eg. cough muscle. flow limitation and effectively is usually expectorate Precipitators of and Dyspnea progressive secretions. allergic type or expectorate and pollution to a respiratory secretions. Productive associated minimum, reactions that can cough with an eg. dust, ‘rigger or inflammatory smoke and exacerbate onset VIS taken as response in feather of acute episode. follows: the lungs pillows, stimulated by according to 1:367 initants. individual P57 ‘Common situation 25 cause of Encourage or + Provides patient Bp: 100/80 COPD is, assist with with some means \ cigarette pursed lip 10 cope or control smoking, ait breathing dyspnea and pollution, exercises. reduce air tapping allergens and Observe Coughing is most infections that characteristics | effective in an may also act of cough like Upright postion or as imritants. porsistent or head down posit hacking or moist. Assist percussion. with measures to improve effeciivenass © cough effortmedication as prescribed by the physician. Provide supplemental humidification like nebulizer. Avariety of medications may be used to decrease mucus and to improve respiration. Humidity helps. reduce viscosity of secretions; ~~ facilitating expectoration, and may reduce or _ prevert formation of thick mucus ~_ plugs in © bronchioles.NURSING CARE PLAN ASSESSMENT |__DIAGNOSIS_|_INFERENCE PLANNING [INTERVENTION | RATIONALE _| Subjective: “Hindi gumagaling ang sugat ko" (My ‘wounds are not heating) aS verbalized by the patient. Objective: + Flushed appearance. Wound drainage. VIS taken as follows: 137.4 P87 R19 BP: 120/90 Risk for infection related to high glucose levels, decreased leukocyte function. Type 2 diabetes melitus occurs: wien the pancreas produces insufficient amounts of the hormone insulin and/or the bodys tissues become resistant to normal or even high levels of insuli This causes high blood glucose (sugar) levels, which can lead to a number of complications it unteated, After 8 hours of nursing interventions, the patient willidentity interventions to prevent or reduce risk of infection. Independent: Observe for signs of infection and inflammation. Promote good handwashing by ‘nurse and patient. Maintain aseptic technique for IV insertion procedure, administration of medications, and site care. Rotate IV sites as indicated. Provide catheter or perineal care. Teach the female patientto clean from front to back after elimination. Provide conscientious skin care. gentl EVALUATION. Afier 8 hours of nursing intervention sethe patient was able to identity intervention s to prevent or reduce tisk of infection. Patiant may be admitted with could nave precipitated the ketoacidotic state, or may develop a ysocomial infection. Reduces the risk of cross- contamination High glucose in the blood creates an excellent medium for bacterial growth. Minimizes the risk for infection. Peripheral circulation may be cd,