REPUBLIC OF THE PHILIPPINES

UNIVERSITY OF NORTHERN PHILIPPINES

TAMAG, VIGAN CITY
2700 ILOCOS SUR

NURSING CARE PLANS

BAÑEZ, JAZZLEY JONES C.

BSN IV-D
DATA NURSING SCIENTIFIC GOAL/ NURSING RATIONALE EVALUATION
DIAGNOSIS BACKGROUND OBJECTIVE INTERVENTIONS

Subjective: Ineffective Airway Ineffective Airway Short term: Independent Short term:
“Rodrigo complains of Clearance related to Clearance is a common After 4 hours of Established rapport Rapport is important to After 4 hours of
difficulty of increased sputum NANDA-I nursing nursing interventions, gain patient’s nursing interventions,
breathing and chills.” production secondary diagnosis for the Patient will cooperation and reduce the patient identified
As verbalized by the to pneumonia as pneumonia nursing identify/demonstrate anxiety. /demonstrated
wife of the patient evidenced by care plans. This behaviors to achieve behaviors to achieve
productive cough diagnosis is related to airway clearance. Obtained resting vital Baseline data is airway clearance.
Objective: with yellowish to green excessive secretions Signs important to help Goal met
BP: 110/70 mmHg color of and ineffective cough Long Term: determine patient’s
T: 38.2°C/axilla sputum or nonproductive After 1 day of nursing current health status Long Term:
PR: 112 bpm coughing. interventions, the and evaluate efficacy After 1 day of nursing
RR: 24 cpm Inflammation and Patient will of nursing interventions, the
increased secretions in display/maintain patent interventions rendered. Patient
(+)difficulty of pneumonia make it airway with breath displayed/maintained
breathing difficult to maintain a sounds clearing; Placed patient in a An upright position patent airway with
 Chills patent airway. absence of dyspnea, semi-Fowler’s to high- promotes lung breath sounds clearing;
 crackles on both cyanosis, as evidenced Fowler’s position expansion and absence of dyspnea,
lungs by keeping a patent mobilization of cyanosis, as evidenced
 productive cough airway and effectively secretions. by keeping a patent
with yellowish to clearing secretions. airway and effectively
green color of Repositioned patient Frequent repositioning clearing secretions.
sputum every 2 hours prevents pooling and Goal partially met
stasis for secretions.

Encouraged increase in Warm liquids aid in

oral fluid intake; mobilization of
offered warm liquids secretions.

Assisted patient with Deep breathing

deep-breathing facilitates maximum
exercises. expansion of the lungs
Demonstrated proper and smaller airways.
splinting of the chest Coughing is a natural
and effective coughing self-cleaning
while in an upright mechanism assisting
position. Encouraged cilia to maintain patent
patient to do so often. airways. Splinting
reduces chest
discomfort and an
upright position favors
deeper more forceful
cough effort.
Dependent:
Administered
medications as Bronchodilators aid in
ordered: antibiotics, reduction of
mucolytic, bronchospasm.
expectorants, and Mucolytics and
bronchodilators Expectorants mobilize
secretions. Antibiotic
therapy for pneumonia.
Administered
supplemental oxygen Supplemental oxygen
via face mask as aids in ventilation and
ordered minimizes the risk for
hypoxemia.
Collaboration:
Monitored serial x-
rays, ABGs, and pulse Follow the
oximetry readings progress and effects of
disease
process/therapeutic
regimen, and
facilitates necessary
alterations in therapy
DATA NURSING SCIENTIFIC GOAL/ NURSING RATIONALE EVALUATION
DIAGNOSIS BACKGROUND OBJECTIVE INTERVENTIONS

Subjective: Hyperthermia related Hyperthermia in After 4 hours of Independent: After 4 hours of

N/A to the disease process pneumonia is caused nursing intervention, Assessed the patient’s To assist in creating an nursing intervention,
of bacterial pneumonia by the inflammatory the patient’s 38.4ºC vital signs at least accurate diagnosis and the patient’s fever
Objective: as evidenced by Body process and is related body temperature will every 4 hours monitor effectiveness subsided from 38.4 ºC
BP: 110/70 mmHg temperature of to dehydration and decrease to normal of treatment. to 37.3ºC/axilla
T: 38.4°C/axilla 38.4ºC/axilla and rapid infection. range of 36.5°C to Goal partially met
PR: 112 bpm breathing. 37.5 °C/axilla Adjusted and Room temperature may
RR: 24 cpm monitored affect normal body
environmental factors temperature. Blankets
 looks weak and like room temperature and linens may be
pale and bed linens as adjusted as indicated to
 pale palpebral indicated. regulate the patient’s
conjunctiva temperature.

Elevated head of bed Improves the

expansion of lungs,
enabling the patient to
breathe more
effectively.
Eliminated excess
clothing and covers. Room air decreases
warmth and increases
evaporative cooling.
Promotes proper
ventilation.
Offered Tepid sponge
bath. To facilitate the body
in cooling down and
provide comfort.
Dependent:
Administered the
prescribed antibiotics Antibiotic to treat
and anti-pyretic bacterial pneumonia,
medications. anti-pyretic use to
stimulate
hypothalamus and
normalize body
 temperature

DATA NURSING SCIENTIFIC GOAL/ NURSING RATIONALE EVALUATION

DIAGNOSIS BACKGROUND OBJECTIVE INTERVENTIONS

Subjective: Deficient Knowledge A lack of cognitive Short term: Independent: Short term:
Patient verbalized
related to information or After 8 hours of Reviewed normal Promotes After 8 hours of
“detoy ti biagko ken Misinterpretation of psychomotor ability nursing interventions, function and pathology understanding of the nursing interventions,
agas ti saksakiten tiinformation and needed for health the: of condition. situation and the the:
bagik” as reported byUnfamiliarity with the restoration,  Patient and importance of  Patient and
the wife. disease process as preservation, or health caregiver will cooperating with the caregiver
evidenced by promotion is identified verbalize treatment regimen. verbalized
Objective: Statement of as a knowledge deficit. understanding of understanding of
Vital Signs taken as misconception Knowledge plays an condition, disease Discussed debilitating Information can condition, disease
follows: influential and process, and aspects of disease enhance coping and process, and
BP: 90/60mmHg significant part of a prognosis. length of recovery, and help reduce anxiety prognosis.
Temp: 38°C patient’s life and  Patient and expectations. and excessive concern.  Patient and
PR: 122 BPM recovery. Deficient caregiver will caregiver
RR:22 CPM Knowledge nursing verbalize Provided information Fatigue and depression verbalized
diagnosis for understanding of in verbal, written, and can affect ability to understanding of
pneumonia nursing therapeutic or audiovisual forms. assimilate information therapeutic
less hearing acuity care plan includes all regimen. and follow medical regimen.
the teaching plans and regimen. Having Goal partially met
undesirable breath odor interventions for the Long Term: written instructions
sputum is yellowish to patient and caregiver to After 5 days of nursing help client/SO in Long Term:
greenish in color achieve an interventions, the following previous After 5 days of nursing
understanding of the patient will Initiate verbal instructions interventions, the
disease condition and necessary lifestyle patient Initiated
prognosis. changes and participate Emphasized Continuing respiratory necessary lifestyle
in treatment regimen. importance of exercises is necessary changes and
continuing effective for an extended period participated in
coughing and deep- while chest is treatment regimen.
breathing exercises. congested and Goal partially met
secretions are difficult
to manage.

Emphasized necessity Early discontinuation

of continuing of antibiotics may
antimicrobial therapy result in failure to
for prescribed length of completely resolve
time. infectious process.
Reviewed importance Smoking destroys
of cessation of tracheobronchial
smoking. ciliary action, irritates
bronchial mucosa, and
inhibits alveolar
macrophages,
compromising the
body’s natural defense
against infection.

Outlined steps to Increases natural

enhance general health defense, limits
and well-being: exposure to pathogens.
balanced rest, activity
and diet, avoidance of
crowds during cold/flu
season, and persons
with URIs.

Stressed the May prevent

importance of recurrence of
continuing medical pneumonia and/or
follow-up and related complications.
obtaining vaccinations
as appropriate.

Identified signs and Prompt evaluation and

symptoms requiring timely intervention
notification of health may prevent
care provider: complications.
increasing dyspnea,
chest pain, prolonged
fatigue, weight loss,
fever, chills, the
persistence of
productive cough,
changes in mentation.