KATHMANDU UNIVERSITY

SCHOOL OF MEDICAL SCIENCES

DHULIKHEL, KAVRE

Medicine care plan

Submitted to: Submitted by:

Subina Manandhar Rekha Adhikari
Assistant professor Roll no:2
KUSMS BNS 2nd year
DEMOGRAPHIC DATA
Name Ms kali sarki
Age 68years
Sex female
Hospital no
Bed no 8E
Address Dhulikhel-2, Kavrepalanchowk
Ward Medicine ward
Admission date 2023/12/14
Diagnosis AE COPD with type two respiratory failure

Chief complains:
Shortness of breath for 5days
Cough for 4 days
Headache
Chest pain
Actual problem:
Ineffective airway
Activity intolerance
Knowledge deficit
Potential problem;
Risk for impaired skin integrity
Risk for pleural effusion

Actual Nursing Diagnosis

1. Ineffective airway clearance related to copious tracheobronchial

secretions evidenced by sputum production and cough and wheezing
sound.
2. Activity intolerance related to compromised pulmonary function and
generalized weakness as evidenced by limited mobility.
3. Knowledge deficit related to disease condition as evidenced by patient’s
verbalization.
Potential nursing diagnosis:
Risk for impaired skin integrity related to limited mobility.
Nursing care plan: 1
Ineffective airway clearance related to copious tracheobronchial
secretions as evidenced by sputum production and cough.

Assessment Nursing Diagnosis Goal Planning Implementations Rationales Evaluation

Subjective: Ineffective airway After nursing I will Monitor the vital To obtain My
The patient clearance related intervention monitor the signs of the baseline the goal
states that “she to copious patient's vital signs. patient. was met as
data.
feels the tracheobronchial cough will be
sputum stuck secretions as reduced and the patient
in the airway evidenced by the patient was
Help clear
and makes sputum production will achieve Encourage Encouraged able to
secretion
difficulty in and cough. a clear throat deep patient for deep remove the
and
breathing.” and normal breathing breathing and improve secretion ns
breathing and coughing
pattern. breathing and
Objective: On coughing exercises by pattern saturate was
assessment, a exercises by using spirometry
wheezing using also
sound was spirometry 92%at
present, and 4lt O2.
the SPO2 It
level facilitates
Administer Administered airway
83% with O2 bronchodila bronchodilator clearance
at 4 litres per tor inhaler. inhaler. and
minute.
bronchial
dilation
by
relaxing
smooth
muscles

Encourage Encouraged fluid Fluid

fluid intake intake
intake
helps in
thinning
secretion
Nursing care plan:2
Activity intolerance related to compromised pulmonary function and
generalized weakness as evidenced by limited mobility.

Assessment Nursing Diagnosis Goal Planning Implementations Rationales Evaluation

Subjective Activity intolerance The patient’s Assess vital Vital signs were Provide Goal was
data: “I have related to tolerance to signs. assessed baseline partially
difficulty in compromised activity will be data met as
going to the pulmonary increased patient’s
toilet, function and within tolerance
coming out generalized hospitalization Assess the Assessed the Provides to activity
of bed.” weakness . physical physical activity baseline was
activity level and informatio increased
Objective data: level and mobility of the n for for short
The patient mobility of patient. formulatin period only.
seems fatigued the patient g nursing
and lethargic. goals
during
goal
setting.

Help the The patient was Helps in

patient encouraged to increasing
perform perform the the
activities activity more tolerance
slowly. slowly, in a for the
longer time with activity.
more rest or
pauses, or with
assistance if
necessary.

Assist in Assisted in doing To

doing an an active range of minimize
active motion exercises. fatigue
range of and to
motion evaluate
exercises. the
patient’s
capability
and
strength.
Nursing care plan:3
Knowledge deficit related to disease condition as evidenced by
patient’s verbalization.

Assessment Nursing Diagnosis Goal Planning Implementations Rationales Evaluation

Subjective Knowledge deficit The patient’s Assess the The knowledge To collect My object
data: “I want related to disease and visitor’s level of level of the and was fully
to know condition as knowledge knowledge patient about his identify met as the
about my evidenced by about the of the disease was the patient
disease frequent disease patient assessed baseline verbalized
condition questioning by condition will about his data his
” patients and be improved. disease understandin
visitors. condition g of his
Objective data: disease
Patient and condition.
visitor are
anxious and
frequently
asked Determine Determined the This is to
questions about the priority priority of learning know
disease of learning needs. what topic
condition. needs. should be
discussed
and
prioritized

Educate The patient was To

patient educated about provide
about the disease informati
disease condition on about
condition disease
condition.

Explain Treatment It helped

about modalities were to reduce
treatment explained the
modalities anxiety
level and
develop
faith in
treatment
DEMOGRAPHIC DATA

Name Thuli Kanchi Ghorasainee

Age 84 years
Sex Female
Hospital No. 79018192
Bed No. 7D
Address Panchkhal
Ward Medicine ward
Admission date 2023/06/12
Diagnosis Paroxymal Supraventricular Tachycardia(PSVT)

Chief complaints
Palpitation since 1 year but recent since 1 day.
Dizziness on/off.
Throbbing sensation of abdomen rarely.
Actual problem:
Ineffective tissue perfusion
Anxiety
Knowledge
deficiet
Potential
problem:
Risk for decreased cardiac output.
Actual nursing diagnosis
1. Ineffective tissue perfusion related to impaired blood flow due to rapid heart
rate as evidenced by decreased saturation level upto 80%
2. Anxiety related to altered health state as evidenced by fear of palpitations.
3. Knowledge deficit related to disease condition as evidenced by frequent
questioning by patient and visitor.
Potential nursing diagnosis:
Risk for decreased cardiac output related to decrease ventricular filling.

Nursing care plan: 4

Ineffective tissue perfusion related to impaired blood flow due
to rapid heart rate as evidenced by decreased saturation level
up to 80%

Assessment Nursing Diagnosis Goal Planning Implementations Rationales Evaluation

Subjective: Ineffective airway After nursing I will Monitor the vital To obtain My
The patient clearance related intervention monitor the signs of the baseline the goal
states that “she to copious patient's vital signs. patient. was met as
data.
feels the tracheobronchial cough will be
sputum stuck secretions as reduced and the patient
in the airway evidenced by the patient was
Help clear
and makes sputum production will achieve Encourage Encouraged able to
secretion
difficulty in and cough. a clear throat deep patient for deep remove the
and
breathing.” and normal breathing breathing and improve secretion ns
breathing and coughing
pattern. breathing and
Objective: On coughing exercises by pattern saturate was
assessment, a exercises by using spirometry
wheezing using also
sound was spirometry 92%at
present, and 4lt O2.
the SPO2 It
level facilitates
Administer Administered airway
83% with O2 bronchodila bronchodilator clearance
at 4 litres per tor inhaler. inhaler. and
minute.
bronchial
dilation
 by
relaxing
smooth
muscles

Encourage Encouraged fluid

fluid intake Fluid
intake intake
helps in
thinning
secretion

Nursing care plan: 5

Anxiety related to altered health state as evidenced by fear of
palpitations

Assessment Nursing Diagnosis Goal Planning Implementations Rationales Evaluation

Subjective: Ineffective airway After nursing I will Monitor the vital To obtain My
The patient clearance related intervention monitor the signs of the baseline the goal
states that “she to copious patient's vital signs. patient. was met as
data.
feels the tracheobronchial cough will be
sputum stuck secretions as reduced and the patient
in the airway evidenced by the patient was
Help clear
and makes sputum production will achieve Encourage Encouraged able to
secretion
difficulty in and cough. a clear throat deep patient for deep remove the
and
breathing.” and normal breathing breathing and improve secretion ns
breathing and coughing
pattern. breathing and
Objective: On coughing exercises by pattern saturate was
assessment, a exercises by using spirometry
wheezing using also
sound was spirometry 92%at
present, and 4lt O2.
the SPO2 It
level facilitates
Administer Administered airway
83% with O2 bronchodila bronchodilator clearance
at 4 litres per tor inhaler. inhaler. and
minute.
bronchial
dilation
by
 relaxing
smooth
muscles

Encourage Encouraged fluid Fluid

fluid intake intake
intake helps in
thinning
secretion

Nursing care plan: 6

Knowledge deficit related to disease condition as evidenced by
frequent questioning by patient and visitor

Assessment Nursing Diagnosis Goal Planning Implementations Rationales Evaluation

Subjective: Ineffective airway After nursing I will Monitor the vital To obtain My
The patient clearance related intervention monitor the signs of the baseline the goal
states that “she to copious patient's vital signs. patient. was met as
data.
feels the tracheobronchial cough will be
sputum stuck secretions as reduced and the patient
in the airway evidenced by the patient was
Help clear
and makes sputum production will achieve Encourage Encouraged able to
secretion
difficulty in and cough. a clear throat deep patient for deep remove the
and
breathing.” and normal breathing breathing and improve secretion ns
breathing and coughing
pattern. breathing and
Objective: On coughing exercises by pattern saturate was
assessment, a exercises by using spirometry
wheezing using also
sound was spirometry 92%at
present, and 4lt O2.
the SPO2 It
level facilitates
Administer Administered airway
83% with O2 bronchodila bronchodilator clearance
at 4 litres per tor inhaler. inhaler. and
minute.
bronchial
dilation
 by
relaxing
smooth
muscles

Encourage Encouraged fluid Fluid

fluid intake intake
intake helps in
thinning
secretion