LORMA COLLEGES CON TEMPLATE

NURSING CARE PLAN with FDAR

RELATED LEANING EXPERIENCE

STUDENT Macayan, ROTATION: 5th Rotation AREA: Pedia Ward

NAME: Sandara Mae (Respiratory)
YR LEVEL BSN II – 3 DATES: 10/26/23 CLINICAL Ma’am Editha Salbalboro
AND SEC: LEININGER INSTRUCTOR:

PROBLEM: Cough and Cold DIAGNOSIS: Ineffective airway clearance

related to inability to maintain clear airway as
characterized by rapid and shallow breathing
PRIORITIZATION: 1st Prioritization DATE: October 26, 2023

NURSING CARE PLAN 1

ASSESSMENT NURSING PLANNING IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS
Subjective: Ineffective SHORT TERM: INDEPENDENT: INDEPENDENT SHORT TERM
airway after 15 1) Monitored Vital 1) to obtain thr Goal met after
“Ubo ng ubo clearance minutes of Signs every baseline data 15 minutes of
at nahihirapan related to nursing 4hours 2) To help in nursing
na siyang inability to intervention, 2)checked until its regulation of intervention,
huminga kaya maintain clear the patient’s afebrile the body temp the patient’s
tinakbo na airway as respiratory 3) Advice the 3)To promote respiratory
namin” as characterized 30bpm patient on good relaxation and was increased
stated by her by rapid and increased to forceful coughing comfort during 30bpm to
mother shallow 35bpm techniques using sleep 35bpm
breathing abdominal
Objective: LONG TERM: muscles DEPENDENT LONG TERM
after 1hour of 4) replace IVF 1) To treat After 1 hour
Temp- 38.4 nursing with the new one cough and nursing
RR- 30 intervention, fever intervention,
RR- 149 the patient’s DEPENDENT 2) To relieve the patient’s
O2SAT- 95% respiratory 1)Administer of breathlessness maintained
Skin warm to rate maintain nebule as and cough within normal
touch within the prescribed of the thereby range and can
normal range doctor providing breath
and can symptomatic properly
breath 2)Administer of relief
properly paracetamol
 NURSE’S NOTES (FDAR)

PATIENT NAME: CABOTAJE, Chris Jacob S. AGE: 5 years old

PHYSICIAN: SEX: Male
DATE/TIME FOCUS D-ATA A-CTION R-ESPONSE NURSE SIGNITURE
October 21, COUGH AND D- Patient receive lying in bed with an ongoing
2023 COLD IVF of D5IMB 500cc x 50 ugtts/min and
7:00AM received IVF at 200cc level with a regulation of
15 micro drops per minute.
- Monitored Vital Signs: RR-30, PR- 149, 02sat-
92, Temp- 38.9
7:30 AM A- Monitored Temperature due to high fever
(39.2)
7:35 AM - Regulated IVF as prescribed the physician
11:00 AM - Monitored Vital Signs
11:20 AM - Replace new IVF D5IMB 500cc
11:25 AM - Regulate IVF
2:00 PM R- After performing the action, the patient MACAYAN,
demonstrated behaviors to improve clear SANDARA MAE M.
airway and it’s afebrile. The mother said, the
patient already sleeps comfortable