Nursing Care Plan

for senile female patient

Group members
ASSESSMENT DATA
Patient’s Demographic Data Civil status: Married
Name: J.A.S. Religion: Roman Catholic
Age: 42 years old Nationality: Filipino
Address: zxcv, asdf, Occupation: Teacher
qwertty Educational attainment: college Grad
Date of birth: November 2, 1977 Primary caregiver: Husband
Place of birth: asdf, Date of admission: 1 o’clock pm May
qwertty 26, 2019
Gender: Female
CHIEF COMPLAINT:
Difficulty of breathing
PAST HEALTH HISTORY:
Patient has been in good health before she started smoking, had never
been admitted to a hospital due to serious diseases
PRESENT HEALTH HISTORY:
Patient was brought to hospital after she complained of having difficulty
breathing to her daughter a week prior to admission. Accompanying
daughter tells she is a habitual smoker who consumes two to three
sticks of cigarettes per day ever since her husband died thirty years ago.
Furthermore, patient says she had been coughing up thick, yellowish
sputum constantly. During assessment, patient has been speaking in
short, jerky sentences, having to constantly stop to catch her breath and
coughing ineffectively.
OBJECTIVE CUES:
Dyspnea (difficult or labored breathing)
SUBJECTIVE CUES:
“haanak makaanges nga ustu ya ag tupra ak pylang iti plemas”
PHYSICAL ASSESSMENT: Generally a well developed elderly woman
sitting up in bed, breathing with difficulty.
VITAL SIGNS
HEIGHT:155 cm
WEIGHT: 60 kg
BLOOD PRESSURE:*130/70
RESPIRATORY RATE: 38
HEART RATE:82
TEMPERATURE:37.5
NURSING DIAGNOSIS
ACTUAL NURSING DIAGNOSIS:
INEFFECTIVE AIRWAY CLEARANCE; as evidenced by difficulty verbalizing,
dyspnea, excessive sputum, diminished breath sounds (wheezing)
POTENTIAL NURSING DIAGNOSIS: As patient is an elderly smoker, she
has a high chance of chronic obstructive pulmonary disease, lung
infection, activity intolerance, and lung cancer
OUTCOME IDENTIFICATION/OBJECTIVE
Short Term:
After 1 hour of nursing interventions, patient will have ease of breathing,
be able to communicate properly, and have decrease sputum
production.
Long term:
After a week of hospital treatment, patient will have normal vital signs fit
for her age, clear airways, and normal sputum.
NURSING INTERVENTIONS
• Monitor respiration and breath sounds
• Help patient maintain clear airway via
nebulizer (oxygen therapy)
• Encourage deep – breathing exercises
• Increase oral fluid intake
• Support cessation of smoking
• Keep environment free of pollutants
PLANNING
INDEPENDENT PLAN:
• Constant vital sign monitoring
• Increased oral fluid intake
• Breathing exercises
• Advise bed rest
• Put patient into position for ease of breathing
DEPENDENT PLAN:
• Nebulize with bronchodilators (salbutamol/albuterol)per doctor’s orders
• Give antibiotics per doctor’s orders
INTERDEPENDENT PLAN:
• Refer to respiratory therapist for further breathing exercises and medications
IMPLEMENTATION
- Patient responds to plans with willingness, making progress to full restoration of
health

- Patient displays normal breathing pattern

- Patient has lessened mucus production

- Patient understands importance of smoking cessation and is willing to stop

cigarette smoking
EVALUATION
• Patient reports to be able to breath normally
• Breathing sounds are normal
• Mucus excretion is clear
• Nursing care plan is fully met