Name: Arma, Gercia Jade O.
Section: BSN-3A Student Number: 22-01042
Date: Nov. 17, 2024
Patients Identifier: T.M.
Age: 50 yrs. Old
Chief Complaint: Cough, Dyspnea
Admission Diagnosis: GERD, PVD, BAIAE
NURSING CARE PLAN
Assessment Nursing Rationale Planning/Goals Nursing Rationale Evaluation
Diagnosis Intervention
Subjective: Readiness for Demonstration of Short Term: Independent: nursing
“Okay na po Enhanced behaviors or cues After 8 hours of Encourage Adequate interventions the
tak paghinga Therapeutic that reflect the nursing the patient to hydration patient will be able
ngan okay na Management learners interventions the drink plenty helps to thin to:
liwat tak batok, related to stable motivation to learn patient will be able of fluids, secretions, Pt will be
wara na.” as health condition at a specific time. to: monitoring making able to
verbalized by and Reflects not only Pt will be fluid intake them easier report
the patient. patient’s the desire able to and output. to cough up ease of
comprehension of or willingness to report ease and breathing.
Objective: discharge learn but also the of Encourage reducing
- No cough Instructions. ability to learn at breathing. the patient to cough Pt will
noted specific time. rest frequency. establish
- No dyspnea Pt will frequently, a normal
noted establish a pacing Rest and effective
- Patient is normal activities and energy breathing
relaxed and effective avoiding conservatio pattern.
comfortable. breathing strenuous n can Achieve
pattern. exertion. reduce effective
V/s taken as respiratory breathing
follows: Achieve Dependent: effort. pattern.
BP: effective Remind
130/80 breathing patient to Ensures The Goal was Met.
RR: pattern. take optimal
18cpm medication therapeutic After 2 days of
PR: 68 Long Term as effectivenes nursing
bpm After 2 days of prescribed. s, minimizes intervention the
T: 36.6C nursing intervention
Remind adverse patient was able
SPO2: 96% the patient will be patient on effects, to:
able to: follow-up supports
Maintain acheck up. disease Maintain a
respiratory rate managemen respiratory
within normal Collaborative: t, and rate within
range. Report any enhanced normal range.
changes in patient
Verbalize the patient's safety.
understanding condition or Verbalize
of information response to To timely understanding
gained. treatment to monitor the of information
Use information the physician health gained.
to develop promptly. status, and Use information
individual plan to early to develop
meet health care detection of individual plan
needs/goals. any to meet health
potential care
complication needs/goals.
s or
changes in The Goal was Met.
condition.
Regular
communicati
on with the
physician is
essential to
monitor the
patient's
progress,
adjust
medications,
and address
any
concerns.
