(GROUP 3) FUNDAMENTALS OF NURSING PRACTICE LEC

Case: Patient with cough and cold (female)

31 years old
 Headache
 Body weakness
 Shortness of breath

NURSING CARE PLAN

Assessment Nursing Diagnosis Planning Intervention Evaluation

Subjective data: Impaired gas Patient will >Administered >Patients oxygen

>”Nahihirapan akong exchange related to demonstrate supplemental saturation levels to
huminga dahil sa respiratory distress improved gas oxygen as ordered 92 percent.
sipon at ubo ko”. as evidence by exchange as to maintain
shortness of breath, evidence by oxygen saturation >Lung sounds
>Patients reports a cough, and abnormal improved oxygen levels at or above have improved
persistent cough, cold lung sounds. saturation levels 92 percent. and there are no
symptoms, headache, and resolution of signs of
body weakness, and respiratory distress >Assess and respiratory
shortness of breath symptoms. document oxygen distress.
saturation levels
Objective data: and respiratory >Patient reports
>Dyspnea status frequently. decreased
> lung sounds reveal symptoms of
crackles and wheezes, >Encourage the headache, body
and shortness of patient to rest and weakness and
breath limit physical shortness of
activity to breath;
Vital Signs: conserve energy
Temp. 38C and decrease >Patient
PR: 90 bpm oxygen demand. demonstrates
RR: 22 bpm proper hand
BP: 120/80 mmHg >Administer hygiene and
prescribed respiratory
medications, such hygiene
as bronchodilators techniques.
and
corticosteroids, to >Patient is able to
improved lung use cough
function and etiquette to reduce
 relieve symptoms. the risk of
transmitting
>Assess and respiratory
manage pain and secretions to
headache others
symptoms as
appropriate.

>Monitor fluid
intake and output
to ensure
adequate
hydration.

>Educate the
patient on proper
hand hygiene to
prevent the spread
of infection

>Encourage the
patient to use
cough etiquette to
reduce the risk of
transmitting
respiratory
secretions to
others.

Brian Dimayacyac
Abegail Dela Cruz
Kaye Cei Castillo
Humprey Gilbert Fanoga V
Rea Kristel Malapitan
Lara Mae Matira
Des Belen
Grandlee Delos Reyes
David Andrie Digno