Nursing Care Plan

Medical Colleges of Northern Philippines
Alimannao Hills, Peñablanca Cagayan

Telefax No.: (078) 304-1010 Website: www.mcnpisap.com
E-mail Address: adminoffice@mcnp.edu.ph
COLLEGE OF NURSING
BORJA, MICAELA D.
BSN 2C – CA1
NURSING CARE PLAN #1
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Ineffective Airway Short term: Dependent: GOAL MET:
-difficulty of breathing Clearance related to After 4 hours of - Administered - to promote Short term:
pneumonia as nursing intervention, medications as bronchial dilation After 4 hours of nursing
Objective: evidenced by crackles the patient will be able indicated. and mucus intervention, the
-crackles on bilateral on bilateral lungs, to maintain airway clearance. patient was able to
lungs difficulty of breathing patency. maintain airway
and decreased in Independent: patency.
Vital Signs: oxygen saturation. Long term: - Monitored respirations -indicative of
BP: 140/90 After 24 hours of and breath sounds, respiratory distress Long term:
Temp: 38.9°C nursing intervention, noting rate and sounds. and/or After 24 hours of
RR: 26 the patient will be able accumulation of nursing intervention,
PR: 112 to secretions. the patient was able to
O2 Sat: 93 demonstrate reduction demonstrate reduction
of congestion with - Assessed level of - this information is of congestion with
breath sounding clear, consciousness/cognition essential for breath sounding clear,
noiseless respirations, and ability to protect identifying potential noiseless respirations,
and improved oxygen own airway. for airway and improved oxygen
exchange. problems, providing exchange.
baseline level of
care needed.
- Elevated the head of

bed, encouraged early - to prevent
COLLEGE OF NURSING
ambulation, or changed complications such

client’s position every 2 as aspiration,
hr. atelectasis, and
pressure ulcers.
- Keep environment
allergen free. - helps minimize
respiratory irritants
and respiratory
distress.
Collaborative:
- Demonstrated/assisted
the client/SO in -to improve
performing specific ventilation and
airway clearance prevent respiratory
techniques as indicated. complications.
COLLEGE OF NURSING

Subjective: Impaired Gas Exchange Short term: Dependent: GOAL MET:
-difficulty of breathing related to altered After 4 hours of -Administered - to prevent and Short term:
oxygen supply as nursing intervention, medications as control symptoms, After 4 hours of nursing
Objective: evidenced by crackles the patient will indicated. reduce frequency intervention, the
-crackles on bilateral on bilateral lungs, participate in and severity of patient was able to
lungs infiltrates on x-ray, treatment regimen exacerbations. participate in treatment
-infiltrates is seen in his difficulty of breathing, within level of ability or regimen within level of
x-ray and oxygen saturation situation. Independent: ability or situation.
of 93%. - Monitored and - to ensure safe and
Vital Signs: Long term: instructed the client in effective medication Long term:
BP: 140/90 After 24 hours of therapeutic and adverse management and After 24 hours of
Temp: 38.9°C nursing intervention, effects of medication. enhances patient nursing intervention,
RR: 26 the patient will understanding. the patient was able to
PR: 112 demonstrate improved demonstrate improved
O2 Sat: 93 % ventilation, adequate - Assessed respiratory - this provides ventilation, adequate
oxygenation of tissues, rate, depth, use of insight into the oxygenation of tissues,
and absence of accessory muscles, and work of breathing and absence of
respiratory distress. pursed-lip breathing. and adequacy of respiratory distress.
alveolar ventilation.
- Encouraged adequate - this helps limit

rest and limit activities. oxygen needs and
consumption.
- Elevated the head of -elevation or upright

the bed and positioned position improves
the client appropriately. lung expansion.
COLLEGE OF NURSING
Collaborative:
-Encourage frequent - this promotes
position changes and optimal chest
deep-breathing and expansion,
coughing exercises. Use mobilization of
incentive spirometer, secretions, and
chest physiotherapy, oxygen diffusion.
and intermittent
positive-pressure
breathing, as indicated.
COLLEGE OF NURSING

Subjective: Ineffective peripheral Short term: Dependent: GOAL MET:
-edema on lower Tissue Perfusion After 8 hours of - Administered -to improve tissue Short term:
extremities related to diabetes nursing intervention, medications as ordered. perfusion and After 8 hours of nursing
mellitus and the patient will be able prevent clot intervention, the
hypertension as to verbalize formation. patient was able to
Objective: evidenced by edema understanding of risk verbalize understanding
-patient has hx of on lower extremities. factors or condition, Independent: of risk factors or
hypertension for 5 therapy regimen, side - Assessed skin color, - helps in condition, therapy
years and also diabetic. effects of medications, temperature, and determining regimen, side effects of
and when to contact moisture. location and type of medications, and when
Vital Signs: healthcare provider. perfusion problem. to contact healthcare
BP: 140/90 provider.
Temp: 38.9°C Long term: - Measured the capillary - to determine
RR: 26 -After 2-3 days of refill. adequacy of Long term:
PR: 112 nursing intervention, systemic circulation. -After 2-3 days of
O2 Sat: 93 the patient will be able nursing intervention,
to demonstrate - Inspected the lower - to identify the patient was able to
Laboratories: behaviors and lifestyle extremities for skin potential changes in demonstrate behaviors
Hgb: 8 changes to improve texture skin integrity, and lifestyle changes to
Creatinine: 120 circulation. moisture levels, and improve circulation.
HbA1c: 8 overall condition.
Collaborative:
- Administered fluids, - to promote
electrolytes, nutrients, optimal blood flow,
and oxygen, as organ perfusion,
indicated. and function.
COLLEGE OF NURSING

Subjective: Hyperthermia related After 3 hours of Dependent: GOAL MET:
-fever to inflammatory nursing intervention, - Administered - to control After 3 hours of nursing
response as evidenced the patient will medications as ordered. shivering and intervention, the
Objective: by fever (temperature: maintain core seizures. patient was able to
Vital Signs: 38.9°C) and elevated temperature within maintain core
BP: 140/90 white blood cell count normal range. Independent: temperature within
Temp: 38.9°C (WBC: 14,000). - Monitored core normal range.
RR: 26 temperature. -helps to identify
PR: 112 the development of
O2 Sat: 93 the patient’s
temperature.
Laboratories: - Noted the presence or
WBC: 14,000 absence of sweating. - helps to determine
the degree of
hyperthermia and
potential
thermoregulatory
dysfunction.
- Provided tepid sponge
bath. -to reduce fever by
promoting heat loss
through conduction
and evaporation.
-Encouraged patient to
maintain bed rest. -to conserve energy
and reduces
COLLEGE OF NURSING
metabolic demands.
Collaborative:
- Provided high-calorie - increased
diet, enteral nutrition, metabolic demands
or parenteral nutrition. and helps meet
nutritional
requirements for
optimal recovery.
COLLEGE OF NURSING

Subjective: Risk for Infection Short term: Dependent: GOAL MET:
-fever related to pneumonia After 1 hour of nursing - Administered - to prevent Short term:
and elevated white intervention, the medications as bacterial infections After 1 hour of nursing
Objective: blood cell (WBC) count patient will be able to indicated. and stimulate the intervention, the
Vital Signs: as evidenced by WBC identify interventions immune response, patient was able to
BP: 140/90 count of 14,000 to prevent or reduce reducing the risk of identify interventions to
Temp: 38.9°C risk of infection. potential infections. prevent or reduce risk
RR: 26 of infection.
PR: 112 Long term: Independent:
O2 Sat: 93 After 3 days of nursing -Performed the proper - to prevent the Long term:
intervention, the hand washing technique transmission of After 3 days of nursing
Laboratories: patient will before and after any microorganisms and intervention, the
WBC: 14,000 demonstrate procedure done to the promoting patient patient was able to
techniques and patient. safety. demonstrate
lifestyle changes to techniques and lifestyle
promote safe - Provided a clean, well- - to helps minimize changes to promote
environment. ventilated environment. the accumulation of safe environment.
pathogens.
- Monitored the client’s - to limit exposures,

visitors and caregivers thus reducing cross-
for respiratory illnesses. contamination.
Collaborative:
-Provided information - to help promote a
COLLEGE OF NURSING
on infection prevention safe and hygienic

measures to the SO. environment.

Subjective: Activity Intolerance Short term: Independent: GOAL MET:
-easy fatiguability related to imbalance After 8 hours of -Monitored vital and - helps identify early Short term:
-difficulty of breathing between oxygen supply nursing intervention, cognitive signs. signs of After 8 hours of nursing
and demand as the patient will be able physiological intervention, the
Objective: evidenced by increased to: distress and patient was able to:
Vital Signs: respiratory rate, - use identified inadequate - use identified
BP: 140/90 difficulty of breathing, techniques to enhance oxygenation. techniques to enhance
Temp: 38.9°C and fatigue. activity tolerance. activity tolerance.
RR: 26 - participate willingly in - Monitored response to - to ensure optimal - participate willingly in
PR: 112 necessary/desired supplemental oxygen patient response to necessary/desired
O2 Sat: 93 activities. and medications. interventions and activities.
facilitates timely
Long term: adjustments for Long term:
After 5 days of nursing improved After 5 days of nursing
intervention, the oxygenation. intervention, the
patient will patient was able to
demonstrate a - Assessed the client’s - this provides a demonstrate a decrease
decrease in current activity level and baseline for in physiological signs of
physiological signs of physical condition. comparison and an intolerance.
intolerance. opportunity to track
changes.
- Planned care to - to reduce fatigue.

carefully balance rest
periods with activities.
COLLEGE OF NURSING
- Assisted with activities - to protect patient

and provide/monitor from injury.
client’s use of assistive
devices (e.g., crutches,
walker, wheelchair, or
oxygen tank).
Collaborative:
- Provided referral to - to develop
other disciplines, such as individually
exercise physiologist, appropriate
psychological therapeutic
counseling/therapy, regimens.
occupational/physical
therapists, and
recreation/leisure
specialists, as indicated.
COLLEGE OF NURSING
Nursing care Plan (FDAR) #1
FOCUS DATA ACTION RESOLUTION

Ineffective Airway Clearance Subjective: - Administered medications as Short term:
related to pneumonia as evidenced -difficulty of breathing indicated, to promote bronchial Within 4 hours after start of
by crackles on bilateral lungs, dilation and mucus clearance. intervention, the patient was able to
difficulty of breathing and Objective: maintain airway patency.
decreased in oxygen saturation. -crackles on bilateral lungs - Monitored respirations and breath
sounds, noting rate and sounds. Long term:
Vital Signs: Indicative of respiratory distress Within 24 hours after start of
BP: 140/90 and/or accumulation of secretions. intervention, the patient was able to
Temp: 38.9°C demonstrate reduction of
RR: 26 - Assessed level of congestion with breath sounding
PR: 112 consciousness/cognition and ability clear, noiseless respirations, and
O2 Sat: 93 to protect own airway. This improved oxygen exchange.
information is essential for
identifying potential for airway
problems, providing baseline level
of care needed.
- Elevated the head of bed,

encouraged early ambulation, or
changed client’s position every 2
hrs, to prevent complications such
as aspiration, atelectasis, and
pressure ulcers.
- Keep environment allergen free, to

minimize respiratory irritants and
respiratory distress.
COLLEGE OF NURSING
- Demonstrated/assisted the
client/SO in performing specific
airway clearance techniques as
indicated, to improve ventilation
and prevent respiratory
complications.
COLLEGE OF NURSING

Impaired Gas Exchange related to Subjective: -Administered medications as Short term:
altered oxygen supply as evidenced -pt complained for difficulty of indicated, to prevent and control Within 6 hours after start
by crackles on bilateral lungs, breathing symptoms, reduce frequency and intervention, the patient was able to
infiltrates on x-ray, difficulty of severity of exacerbations. participate in treatment regimen
breathing, and oxygen saturation of Objective: within level of ability or situation.
93%. -crackles on bilateral lungs - Monitored and instructed the
-infiltrates is seen in his x-ray client in therapeutic and adverse Long term:
effects of medication, to ensure Within 2-3 days after start
Vital Signs: safe and effective medication intervention, the patient was able to
BP: 140/90 management and enhances patient demonstrate improved ventilation,
Temp: 38.9°C understanding. adequate oxygenation of tissues,
RR: 26 and absence of respiratory distress.
PR: 112 - Assessed respiratory rate, depth,
O2 Sat: 93 % use of accessory muscles, and
pursed-lip breathing. This provides
insight into the work of breathing
and adequacy of alveolar
ventilation.
- Encouraged adequate rest and

limit activities, to helps limit oxygen
needs and consumption.
- Elevated the head of the bed and

positioned the client appropriately.
Elevation or upright position
improves lung expansion.
COLLEGE OF NURSING
-Encourage frequent position

changes and deep-breathing and
coughing exercises. Use incentive
spirometer, chest physiotherapy,
and intermittent positive-pressure
breathing, as indicated, to promote
optimal chest expansion,
mobilization of secretions, and
oxygen diffusion.
COLLEGE OF NURSING

Ineffective peripheral Tissue Subjective: - Administered medications as Short term:
Perfusion related to diabetes -edema on lower extremities ordered, to improve tissue Within 8 hours after start of
mellitus and hypertension as perfusion and prevent clot intervention, the patient was able to
evidenced by edema on lower Objective: formation. verbalize understanding of risk
extremities. -patient has hx of hypertension for 5 factors or condition, therapy
years and also diabetic. - Assessed skin color, temperature, regimen, side effects of
and moisture, to help in medications, and when to contact
Vital Signs: determining location and type of healthcare provider.
BP: 140/90 perfusion problem.
Temp: 38.9°C Long term:
RR: 26 - Measured the capillary refill, to -Within 2-3 days after start of
PR: 112 determine adequacy of systemic intervention, the patient was able to
O2 Sat: 93 circulation. demonstrate behaviors and lifestyle
changes to improve circulation.
Laboratories: - Inspected the lower extremities for
Hgb: 8 skin texture, to identify potential
Creatinine: 120 changes in skin integrity, moisture
HbA1c: 8 levels, and overall condition.
- Administered fluids, electrolytes,

nutrients, and oxygen, as indicated,
to promote optimal blood flow,
organ perfusion, and function.

Nursing Care Plan

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Medical Colleges of Northern Philippines

Alimannao Hills, Peñablanca Cagayan

NURSING CARE PLAN #1

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

- Elevated the head of

ambulation, or changed complications such

NURSING CARE PLAN #2

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

- Encouraged adequate - this helps limit

- Elevated the head of -elevation or upright

NURSING CARE PLAN #3

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

NURSING CARE PLAN #4

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

NURSING CARE PLAN #5

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

- Monitored the client’s - to limit exposures,

on infection prevention safe and hygienic

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

- Planned care to - to reduce fatigue.

- Assisted with activities - to protect patient

Nursing care Plan (FDAR) #1

FOCUS DATA ACTION RESOLUTION

- Elevated the head of bed,

- Keep environment allergen free, to

Nursing care Plan (FDAR) #2

FOCUS DATA ACTION RESOLUTION

- Encouraged adequate rest and

- Elevated the head of the bed and

-Encourage frequent position

Nursing care Plan (FDAR) #3

FOCUS DATA ACTION RESOLUTION

- Administered fluids, electrolytes,

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