NURSING CARE PLAN

Name of Patient: ___ _____Cartagena, Segundino___________ ________ Age: __74____ Civil Status: ____Married__ Sex: ____M____Religion: Roman Catholic
Address: ________________________________________Informant: _____________________ Relationship: _________________________________________
Chief Complaint: _______Dyspnea ____________ _________ Medical Diagnosis: _______________Pleural Effusion Left Probably Parapneumonic _______________

Date PROBLE ASSESSMEN NURSING PLANNING IMPLEMENTATION

M LIST T (cues & DIAGNOS (Objectives- EVALUATION
(According evidences/ IS long & short Rationale/ Justifications
to priority) Objective & term) Nursing Interventions (Nursing Theories of Care, Reference
Maslow’s subjective) Developmental stage,
Hierarchy tasks, Principles, EBP,
of Needs Standards of Nursing
Practice)

Risk for Subjective: Risk for Short term: Independent: N Short term:
ineffective “Kung ineffective • Abnormal breath A
breathing tanggalon ang breathing After 8 hours 1. Assess the sounds can be N Goal fully met. After
pattern. oxygen pattern as of nursing breathing heard as fluid D 8 hours of nursing
maglisud ko evidenced intervention: pattern and accumulate. A intervention:
ug ginhawa” by mild factors that • If the nasal
Objective: increase in - the patient makes it hard cannula is not 15TH - the patient was
Septe -RR:22 respiratory will be for the patient to placed properly, it Edition relieved from
mber -Use of rate relieved from breath will be more Doenges difficulty in breathing
8, accessory difficulty in 2. Recheck if difficult for the et. al, 2019 as evidence by no use
2023 muscles while breathing oxygen therapy patient to get Pages of accessory muscle
breathing is infusing well. oxygen since 27-23 while breathing.
-Poor -the patient 3. Monitor Intake there is a
positioning will be able to and Output hindrance in -The patient was able
-Irritated and exercise and 4. Assess and breathing. to exercise and
uncomfortable demonstrate record vital • Patient with demonstrate proper
behavior proper signs pleural effusion breathing pattern and
-with AV breathing 5. Position the needed to be positioning.
fistula @ left technique client in a semi- monitored
-post fowler position continuously
hemodialysis 6. Perform Bed because to know
-74 years old side care if there are any
underlying
-Oxygen 7. Encourage to disease happening
Therapy increase fluid in the lungs.
@2L/m intake • Vital Signs would
Dependent: serve as the
1. Administer baseline and
medication as indication if
prescribed something is
2. Provide abnormal.
postural as
ordered • Assessing clients
3. Report any position helps you
unusuality to what should
CI or NOD position should
Collaborative you use.
1. Check patient’s • Semi-fowler’s
chest x-ray position improve
2. Read laboratory the airway
results • Bed side care
promotes good
environment and
establish rapport
• Increasing her
fluid intake will
help the patient
recover more
faster
Dependent
• Drugs that
weren’t
prescribed by the
doctor means
harmful
• We should rely on
doctors first.
• Reporting
unusualities will
help the CI or
NOD address the
problem
immediately.
Collaborative:
 • Helps you to
address if there
any fluid, blood
or injuries in the
lungs.
• Reading
laboratories can
indicate if there’s
continuation of
accumulation of
fluid in the cavity
or lungs.

Name of Student Nurse & Signature: Jamil C. Acob, SNBC and Section: __BSN 3-A______Date/Duration of Patient Care: September 8, 2023 7-3PM Shift
Name of Clinical Instructor: ___ Aileen Gladys Bunda RN___________Rating: _______________________ Remarks: _______________________