ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING
West Avenue, Molo, Iloilo City
NURSING CARE PLAN
Defining Characteristics Nursing Diagnosis Outcome Nursing Interventions Rationale Evaluation
Identification
Subjective: Long Term: Independent: -As airway gets narrow, client Goals are met
Ineffective airway clearance After 24 hrs of nursing Assess the client for the demonstrates increase respiratory
“I have thick, itchy sensation in related to Laryngeal edema interventions, patient sensation of a narrowed effort. Patient maintains an
the throat, felt shortness of breath and bronchospasm as will maintain an airway. effective breathing
and chest tightness”, as verbalized evidenced by chest tightness, effective breathing pattern as evidenced
by the patient shortness of breath, and pattern, as evidenced by Monitor oxygen -As shock progresses, aerobic by relaxed
cyanosis relaxed breathing at saturation and arterial metabolism stops and lactic breathing, absence
normal rate and depth blood gasses acidosis occurs, resulting in the of adventitious
and absence of increased level of carbon dioxide breath sounds, and
adventitious breath and decreasing pH. Angioedema, lessen
Objective: Rationale: sounds. urticaria, peripheral
Anaphylaxis also called Assess the client’s -Life-threatening situations such as cyanosis, and
severe urticaria (arms, legs, face) allergic or anaphylactic anxiety level. respiratory distress and shock laryngospasm were
angioedema (throat, tongue) shock, is a sudden, severe, Provide assurance and can produce elevated levels of fully resolved.
Oxygen Saturation-92%, with and life-threatening allergic alleviate anxiety by anxiety within the client. Air
wheezing sound, heard at the right reaction that involves the Short Term: staying with the client hunger can produce an extremely
upper lobe. whole body. The reaction is After 1 hour of nursing during acute distress. anxious state that leads to rapid
peripheral cyanosis marked by constriction of the intervention, and shallow respirations.
airways, leading to difficulty Angioedema, urticaria,
breathing. Swelling of the peripheral cyanosis, and Instruct the client to -Focus breathing may help calm
throat may block the airway laryngospasm will fully breathe slowly and the client, and the increased tidal
in severe cases. resolve deeply. volume facilitates improved gas
exchange.
Position the client -to provide oxygenation by
upright. promoting maximum chest
expansion and is the position of
Note: Nursing Diagnosis choice during respiratory
should be based on distress.
(NANDA- Approved
Nursing Diagnosis)
Dependent:
Hartmann’s solution
1000ml was started at
125 cc/hr.
Administer 100% O2 -Oxygen increases arterial
via non-rebreather saturation. Oxygen saturation
mask as ordered. that is less than 90% results in
tissue hypoxia, acidosis,
dysrhythmias, and changes in the
level of consciousness.
Epinephrine 0.5mg IM
(1st dose & after 10 -It is fast-acting and relaxes
mins 2nd dose) was pulmonary vessels to improve air
given as ordered exchange and stabilize cellular
permeability.
Salbutamol 5mg/2.5ml
via nebulizer was given -help open the airways in the lungs
as ordered. by relaxing smooth muscles
around the airways.
Diphenhydramine HCL
( Benadryl )50 mg -is an antihistamine mainly used to
IVTT every 8 hours x 3 treat allergies.
doses
8-4-12
Cefuroxime ( Zinnat)
500 mg BID IVTT -a broad-spectrum antibiotic, to
ANST was given as prevent infection
ordered
PAI with Salbutamol 1
nebule every 8 hours -bronchodilator, used to treat
was given as ordered wheezing and shortness of breath
caused by breathing problems
ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING
West Avenue, Molo, Iloilo City
NURSING CARE PLAN
Defining Characteristics Nursing Diagnosis Outcome Nursing Interventions Rationale Evaluation
Identification
Subjective: Long Term: Independent: -Tachycardia may be present Goals are met
Decrease Cardiac Output After 8 hrs of nursing Monitor vital signs and because of pain, anxiety,
" Galingin ang akon ulo,kag related to Generalized intervention, the cardiac rhythm hypoxemia, and reduced cardiac After all the nursing
gapin- ot pa dughan ko", as vasodilation as evidenced by patient's risk for output. Changes may also occur intervention the
verbalized by the patient. hypotension decreased cardiac in BP (hypertension or client showed
output will be lessen as hypotension) because of cardiac improvement and
evidenced by normal response. ECG changes no dyspnea noted.
Blood Pressure (WNL) reflecting dysrhythmias indicate BP is 120/ 80
Objective: Rationale: need for additional evaluation mmHg. PR is 90
During anaphylaxis, small and therapeutic intervention. bpm
angioedema (throat, tongue) blood vessels (capillaries) Also, to provide baseline data for
Oxygen Saturation-92%, begin to leak blood into your comparison to follow trends and “Wala na gapin-ot
peripheral cyanosis tissues. This can cause a Short Term: evaluate response to intervention. akon dughan kag
dyspnea sudden and dramatic drop in After 1 hour, patient nadula naman lingin
BP 90/60mmHg blood pressure. will verbalize the Maintain bed or chair -Decreases oxygen demand, sang akon ulo”, as
PR-100 bpm absence of chest rest in position of therefore, reducing myocardial verbalized by the
Lab test: tightness and dizziness. comfort during acute workload and risk of patient
Hgb 12.0g/L (low) During anaphylaxis, episodes. (Semi-fowler decompensation.
coronary hypoperfusion position with feet
caused by systemic slightly elevated)
vasodilation, plasma leakage,
loss of volume due to Instruct patient to rest -Conserves energy, reduces cardiac
increased vascular for adequate rest workload.
permeability, and reduced periods.
venous return can contribute
to cardiac output Assess the client’s level -Early signs of cerebral hypoxia
suppression, leading further of consciousness. are restlessness and anxiety
to myocardial damage and while confusion and loss of
ventricular dysfunction memory occurs in late stage.
Assess the skin -Massive vasodilation and
temperature and signs increased capillary permeability
Note: Nursing Diagnosis of any cyanosis. can lead to decreased peripheral
should be based on blood flow and ineffective tissue
(NANDA- Approved perfusion.
Nursing Diagnosis)
-The renal system compensates for
Monitor the client’s low blood pressure by retaining
urine output. Water. Oliguria is a classic sign
of inadequate renal perfusion.
Dependent:
Hartmann’s solution
1000ml was started at
125 cc/hr.
-Increases oxygen available for
Administer 100% O2 myocardial uptake to improve
via non-rebreather contractility, reduce ischemia,
mask as ordered. and reduce lactic acid levels.
-It is fast-acting and relaxes
Epinephrine 0.5mg IM pulmonary vessels to improve air
(1st dose & after 10 exchange and stabilize cellular
mins 2nd dose) was permeability.
given as ordered
-help open the airways in the lungs
Salbutamol 5mg/2.5ml by relaxing smooth muscles
via nebulizer was given around the airways.
as ordered.
-relieve mild to moderate pain
Aspirin 300mg PO
given as ordered
-used to treat angina (chest pain).
NTG (Glyceryl It can help stop chest pain if an
trinitrate ) 1.2mg SL angina attack has already started.
was given as ordered
Hartmann’s solution -to correct for low blood pressure
1000ml was started at or decreased blood volume
125 cc/hr.
Diphenhydramine HCL -is an antihistamine mainly used to
( Benadryl )50 mg treat allergies.
IVTT every 8 hours x 3
doses
8-4-12
Cefuroxime ( Zinnat) -a broad-spectrum antibiotic, to
500 mg BID IVTT prevent infection
ANST was given as
ordered
PAI with Salbutamol 1 -bronchodilator, used to treat
nebule every 8 hours wheezing and shortness of breath
was given as ordered caused by breathing problems
