PHILIPPINE ADVENT COLLEGE

RAMON MAGSAYSAY, SINDANGAN, ZAMBOANGA DEL NORTE

 PHILIPPINE ADVENT COLLEGE
RAMON MAGSAYSAY, SINDANGAN, ZAMBOANGA DEL NORTE

NURSING CARE PLAN

Client: Patient X Age: 3 years old Gender: Male Care Plan by: Group 12
Address: Siari, Sindangan, Z.N. Birthday: June 25, 2020 Religion: RC Date Initiated: October 4, 2023
Chief Complaints: Difficulty of breathing and Non-Productive Cough Civil Status: Single

NURSING DIAGNOSIS: risk for activity intolerance related to decreased oxygenation as evidenced by immobility

ASSESSMENT PLAN OF CARE NURSING RATIONALE EVALUATION

INTERVENTION

Subjective: STG: Independent: STG:

 Patient was incapable After 4 hours of nursing - Monitor v/s - For baseline data After 4 hours of nursing
of verbal intervention, the mother will - Assess motor - To identify causative intervention, the patient was
communication. participate willingly in function factors able to participate deep
 Mother verbalized “di necessary or desired breathing exercises. Goal
kayo sya kalihok sa activities such as deep - Note contributing - To identify met.
anak ma’am kay breathing exercises. factors to fatigue precipitating factors
maglisod siya og
ginhawa” - Evaluate degree of - To identify severity
deficit LTG:
Objective: LTG: - Ascertain ability to - To identify necessity After 2 days of nursing
 Immobility and After 2 days of nursing stand and move about of assistive devices intervention, the patient was
weakness intervention, the mother able to execute slightly his
could do the ADL of the - Assess emotional or - Stress or depression ADL’s with a minimal
T- 38.4 patient with a minimal psychological factors will increase the difficulty of breathing. Goal
P- 21 difficulty of breathing. effect of illness. was partially met.
R- 98 Dependent:
Sp02- 95%
BP- 110/60 - Inhaled steroids as - To open up airways
to treat asthma or
 PHILIPPINE ADVENT COLLEGE
RAMON MAGSAYSAY, SINDANGAN, ZAMBOANGA DEL NORTE

prescribed other lung diseases.

temperature

- To reduce excess
- Administer diuretics fluids in the lungs
if ordered
 PHILIPPINE ADVENT COLLEGE
RAMON MAGSAYSAY, SINDANGAN, ZAMBOANGA DEL NORTE

NURSING CARE PLAN

Client: Patient X Age: 3 years old Gender: Male Care Plan by: Group 12
Address: Siari, Sindangan, Z.N. Birthday: June 25, 2020 Religion: RC Date Initiated: October 4, 2023
Chief Complaints: Difficulty of breathing and Non-Productive Cough Civil Status: Single

NURSING DIAGNOSIS: imbalanced nutrition: less than body requirements related to inadequate intake of nutritious foods secondary to
underlying lung disease as evidenced by loss of appetite and body weakness

ASSESSMENT PLAN OF CARE NURSING RATIONALE EVALUATION

INTERVENTION
Subjective:
 Patient was incapable STG: Independent: STG:
of verbal After 4 hours of nursing - Determine client’s - To determine factors After 4 hours of nursing
communication. intervention, the mother will activity chew, that can affectintervention, the mother was
 Mother verbalized regain body strength and loss swallow, and taste ingestion and able recoup his body strength
“nagluya mani akong of appetite will be relieved. food. digestion of nutrients.and loss of appetite will be
anak ma’am, perting - Auscultate bowel - To evaluate degree of relieved. Goal is met
louya” sounds, note deficit.
Objective: LTG: characteristics of - To reveal possible
 Ineffective cough After 2 days of nursing stool. cause of
 Restlessness intervention, the mother will - Evaluate total daily malnutrition/changes
 Use of accessory demonstrate behaviors to food intake. Obtain that could be made in
muscles if breathing regain and maintain diary of calorie client’s intake. LTG:
 Loss of appetite appropriate weight. intake, patterns and - To promote wellness. After 2 days of nursing
times of eating. intervention, the mother will
 Poor muscle tone
- Emphasize demonstrate behaviors to
T- 38.4
importance of well- regain and maintain
P- 21
balanced nutritious appropriate weight. Goal was
R- 98
intake. partially met.
 PHILIPPINE ADVENT COLLEGE
RAMON MAGSAYSAY, SINDANGAN, ZAMBOANGA DEL NORTE

Sp02- 95% Dependent:

BP- 110/60 - Administer D5LR if
prescribed. - To provide
electrolytes and
calories, and is a
source of water for
hydration.
 PHILIPPINE ADVENT COLLEGE
RAMON MAGSAYSAY, SINDANGAN, ZAMBOANGA DEL NORTE

NURSING CARE PLAN

Client: Patient X Age: 3 years old Gender: Male Care Plan by: Group 12
Address: Siari, Sindangan, Z.N. Birthday: June 25, 2020 Religion: RC Date Initiated: October 4, 2023
Chief Complaints: Difficulty of breathing and Non-Productive Cough Civil Status: Single
NURSING DIAGNOSIS: risk for infection related to worsening in condition leading to immobility immunosuppression and malnutrition

ASSESSMENT PLAN OF CARE NURSING RATIONALE EVALUATION

INTERVENTION
Subjective:
 Patient was incapable of verbal STG: Independent:
communication. After 4 hours of - Monitor for - Dropping blood
 Mother verbalized “nagluya nursing intervention, the worsening signs and pressure, After 4 hours of
mani akong anak ma’am, mother will be aware and infections or sepsis. hypothermia or nursing intervention, the
perting louya” able to determine the hyperthermia, mother was able to be
Objective: possible cause of elevated HR and aware and was able to
 Restlessness worsening the infection. tachypnea that are determine the possible
signs of sepsis that cause of worsening the
T- 38.4 LTG: acquires immediate infection.
P- 21 After 2 days of - Assess laboratory attention.
R- 98 nursing intervention, the values. - An elevated WBC After 2 days of
Sp02- 95% mother will be able to count is indicative in nursing intervention, the
BP- 110/60 demonstrate proper infection. This is an mother was able to
interventions upon expected finding demonstrate proper
protecting the patient from with pneumonia but interventions upon
exacerbating infection. should not continue protecting the patient from
- Implement to rise with exacerbating infection.
precautions to treatment.
prevent infections. - Proper hygiene.
- Consider the sources
 PHILIPPINE ADVENT COLLEGE
RAMON MAGSAYSAY, SINDANGAN, ZAMBOANGA DEL NORTE

of infection
- To refrain the
- Promotes skin patient from being
integrity. contact with any
infection.
- Skin breakdown
allows pathogens to
enter the body. If the
patient immobile,
they have to re-
position every 2
hours.
Dependent: - To kill the bacteria
- Administer or making it difficult
antibiotics if for the bacteria to
prescribed. grow or multiply.
 PHILIPPINE ADVENT COLLEGE
RAMON MAGSAYSAY, SINDANGAN, ZAMBOANGA DEL NORTE

NURSING CARE PLAN

Client: Patient X Age: 3 years old Gender: Male Care Plan by: Group 12
Address: Siari, Sindangan, Z.N. Birthday: June 25, 2020 Religion: RC Date Initiated: October 4, 2023
Chief Complaints: Difficulty of breathing and Non-Productive Cough Civil Status: Single

NURSING DIAGNOSIS: risk-prone health behavior related to stressors as evidenced by failure to take action that prevents health problems

ASSESSMENT PLAN OF CARE NURSING RATIONALE EVALUATION

INTERVENTION
Subjective:
 Patient was incapable of STG: Independent:
verbal communication. After 4 hours of - Encourage client to - The nurse would After 4 hours of nursing
 Mother verbalized nursing intervention, the express his thoughts know underlying intervention, the patient will
“mahadlok jud ako anak sa mother will demonstrate the and feelings. cause of his reluctant demonstrate increasing
injection ma’am” increasing - Client’s mother and can provide for interest/participation in self-
Objective: interest/participation in self- perception of comfortability if care.
 Facial grimace is 5 care. reluctant to complaints are
 Speech was soft and medication noted. After 2 days of nursing
limited LTG: administration. - Perception can affect intervention, the mother will
 Recorded multiple After 2 days of - Inform the mother their behavior. able to communicate the
rejections of nursing intervention, the about the importance - The mother needs to patient’s need,
medications mother will able to of medication know the comfortability, and pain is
 V/s are taken as communicate patient’s need, adherence. consequences of not present.
follows: comfortability, and pain is adhering to
T- 36.4 present. Dependent: medication for it can
P- 21 - Administer interfere with health
R- 98 antibiotics if promotion.
Sp02- 95% prescribed. - Skin breakdown
allows pathogens to
 PHILIPPINE ADVENT COLLEGE
RAMON MAGSAYSAY, SINDANGAN, ZAMBOANGA DEL NORTE

BP- 110/60 enter the body. If the

patient immobile,
they have to re-
position every 2
hours.
- To kill the bacteria
or making it difficult
for the bacteria to
grow or multiply.
 PHILIPPINE ADVENT COLLEGE
RAMON MAGSAYSAY, SINDANGAN, ZAMBOANGA DEL NORTE

NURSING CARE PLAN

Client: Patient X Age: 3 years old Gender: Male Care Plan by: Group 12
Address: Siari, Sindangan, Z.N. Birthday: June 25, 2020 Religion: RC Date Initiated: October 4, 2023
Chief Complaints: Difficulty of breathing and Non-Productive Cough Civil Status: Single

NURSING DIAGNOSIS: disturbed sleep pattern related to interruptions secondary pneumonia

ASSESSMENT PLAN OF CARE NURSING RATIONALE EVALUATION

INTERVENTION
Subjective:
 Patient was incapable of verbal STG: Independent:
communication. After 4 hours of - Discourage intake of - Caffeine can make After 4 hours of nursing
 Mother verbalized “dili nursing intervention, the foods and fluids that patient hyperactive intervention, the patient
katulog og tarong akong anak patient experience are high in caffeine. . experienced decrease
kada gabie kay sigeg ubo-ubo” decreases restlessness, - Offer client an - To provide long restlessness, decrease
Objective: decrease weakness, and evening snack that period of sleep. weakness, and minimal
 Cough minimal diminished of includes milk or diminished of cough. Goal
 Restlessness cough. cheese. met.
 Weakness - Encourage the client - To avoid sleep
 Yawning LTG: to urinate just before disturbance. After 2 days of nursing
After 2 days of the bedtime. intervention, the patient
 V/s are taken as
nursing intervention, the - Providing loose- - Wearing loose experienced state of feeling
follows:
patient will experience fitting nightwear. clothing is important well and rested, and
T- 36.4
state of feeling well and for circulation as diminish yawning. Goal
P- 21
rested, and diminish well as allowing met.
R- 98
yawning. your skin to breathe.
Sp02- 95%
BP- 110/70 - Place the patient in - A proper sleep
comfortable position position can relieve
 PHILIPPINE ADVENT COLLEGE
RAMON MAGSAYSAY, SINDANGAN, ZAMBOANGA DEL NORTE

during bedtime. stress on spine and

prevent any sleep
Dependent: disturbances.
- Administer - To inhibit synthesis
Ceftriaxone 1 mg q of bacterial cell wall
12 if prescribed.
 PHILIPPINE ADVENT COLLEGE
RAMON MAGSAYSAY, SINDANGAN, ZAMBOANGA DEL NORTE

NURSING CARE PLAN

Client: Patient X Age: 3 years old Gender: Male Care Plan by: Group 12
Address: Siari, Sindangan, Z.N. Birthday: June 25, 2020 Religion: RC Date Initiated: October 4, 2023
Chief Complaints: Difficulty of breathing and Non-Productive Cough Civil Status: Single
NURSING DIAGNOSIS: ineffective health maintenance related to secondhand smoke exposure

ASSESSMENT PLAN OF CARE NURSING RATIONALE EVALUATION

INTERVENTION
Subjective:
 Mother stated “akong STG: Independent: After 4 hours of nursing
bana og iyang mga lolo After 4 hours of - Reinforce explanation - To provide intervention, both parents of
sigeg panigarilyo, nursing intervention, both of risk factors opportunities for the patient were aware on
maong mahadlok pud parents of the patient will be restrictions client to retain how the secondhand smoking
baya ko sa akong anak”. aware on how the medications and information and could trigger patient’s
Objective: secondhand smoking could symptoms requiring assume control. condition. Goal met.
 When I entered trigger patient’s condition. immediate medical
the patient’s attention. After 2 days of nursing
room to clarify LTG: - Provides information - To increase intervention, the mother ws
questions, upon After 2 days of nursing about the health community awareness able to efficiently promote
my assessment, I intervention, the mother will impacts of second- about the dangers of and maintain a healthy
found out that be able to efficiently promote hand smoke as well secondhand smoke on environment. Goal was
the father’s was and maintain a healthy as probable diseases one’s health. partially met.
a cigarette environment. or illnesses. - Should prevent
smoker. - Instruct the family to visitors from smoking
 V/s are taken as not allow smoking in while visiting the
follows: their home and post a family’s home, as this
T- 36.4 NO SMOKING sign may put the family at
P- 21 that is easily visible danger for lung
 PHILIPPINE ADVENT COLLEGE
RAMON MAGSAYSAY, SINDANGAN, ZAMBOANGA DEL NORTE

R- 98 and readable by the disease.

Sp02- 95% visitors. -
BP- 110/60 - Contact barangay - To limit secondhand
officials to arrange smoke exposure to
for a designated non-smokers and
smoking spot away reduce cigarettes
from the community. consumption by
- Instruct the family to smokers.
inform their relatives - To totally eliminate
about the authorized exposure to
smoking location. secondhand smoke.
Dependent:
- Administer antibiotics
if prescribed.
 PHILIPPINE ADVENT COLLEGE
RAMON MAGSAYSAY, SINDANGAN, ZAMBOANGA DEL NORTE

NURSING CARE PLAN

Client: Patient X Age: 27 years old Gender: Male Care Plan by:
Address: Tigbao, Sindangan Birthday: July 01, 1995 Religion: RC Date Initiated:
Chief Complaints: Fever, Chills and Vomiting Civil Status: Single

NURSING DIAGNOSIS: impaired gas exchange related to ventilation perfusion imbalance as evidenced by
wheezing
ASSESSMENT PLAN OF CARE NURSING RATIONALE EVALUATION
(PLANNING) INTERVENTION
(IMPLEMENTATION)
Subjective: STG: Independent: After 4 hours of
 Mother stated After 4 hours of - Elevated head of bed - To maintain airway nursing intervention,
“medyo nursing intervention, the or position client - Promotes optimal chest the patient was able
to execute improve
hagushos iyang patient will able to appropriately, expansion and drainage of
ventilation and
pagginhawa sa demonstrate improve provide airway secretion.
adequate oxygenation
akong anak.” ventilation and adequate adjuncts and suction of tissues. Goal was
oxygenation of tissues. as indicated. - Reveals presence of met.
Objective: - . - Encourage frequent pulmonary
 Irritability deep breathing or congestion/collection of After 2 days of
 Restlessness coughing exercises. secretions indicating the nursing
 V/s taken as LTG: - Auscultate breath need for interventions intervention, the
follows: After 2 days of sounds noting patient was able to
T- 36.4 nursing intervention, the crackles, wheezes. - Helpful in diagnosing cooperate in
P- 91 patient will be able to - Monitor v/s various respiratory treatment regimen
R- 30 participate in treatment - Educate and disorders. within level of
Sp02- 95% regimen within level of demonstrate to the ability or situation
BP- 110/60 ability or situation and SO proper - To identify when a patient’s and will be able to
will be able to verbalize positioning. v/s are within the normal verbalize
 PHILIPPINE ADVENT COLLEGE
RAMON MAGSAYSAY, SINDANGAN, ZAMBOANGA DEL NORTE

understanding causative Dependent: ranges. understanding

factors and appropriate - Administer D5LR if causative factors
interventions. prescribed. - To relieve difficulty of and appropriate
- Adding breathing. interventions. Goal
supplemental oxygen was met.
if needed. - To often counteract the
impaired gas exchange by
delivering oxygen directly
into the lungs.

- To deliver purified oxygen

to the user.
 PHILIPPINE ADVENT COLLEGE
RAMON MAGSAYSAY, SINDANGAN, ZAMBOANGA DEL NORTE

NURSING CARE PLAN

Client: Patient X Age: 27 years old Gender: Male Care Plan by:
Address: Tigbao, Sindangan Birthday: July 01, 1995 Religion: RC Date Initiated:
Chief Complaints: Fever, Chills and Vomiting Civil Status: Single

NURSING DIAGNOSIS: ineffective airway clearance RT bronchial secondary to upper respiratory tract
infection
ASSESSMENT PLAN OF CARE NURSING RATIONALE EVALUATION
(PLANNING) INTERVENTION
(IMPLEMENTATION)
Subjective: STG: Independent: After 4 hours of
 Mother After 4 hours of - Observe the signs of - Observing for signs may nursing intervention, the
stated nursing intervention, the respiratory distress further evaluate the patient was able to
reduce the coughing
“akong patient will able to reduce like increase patient’s and can prevent
within the shift using
anak kay the coughing within the respiratory rate, further complications. various nursing
sige og ubo shift using various nursing restlessness or use of - To determine if there any interventions, was
maong interventions, ability to accessory muscles. changes in the gas ability to cough out
maglisod cough out phlegm, and - Monitoring the exchange. phlegm, and the client
siyag enable client to verbalize patient’s breathing enabled client to
ginhawa on how to manage cough. verbalize on how to
pattern. - To promote better lung
manage cough. Goal
pero walay - Put the patient in an expansion. was met.
plema”. LTG: upright or high
After 2 days of fowler’s position. - Controlled coughing helps After 2 days of nursing
Objective: nursing intervention, the - Educate the SO to to loosen and remove intervention, the patient
 Heard the patient will be able to instruct the patient to sputum for better airway was slightly able to
child cough have a complete relief pathway. have a complete relief
do the controlled
from cough and maintain from cough and
during cough. maintained clear and
 PHILIPPINE ADVENT COLLEGE
RAMON MAGSAYSAY, SINDANGAN, ZAMBOANGA DEL NORTE

assessment clear and open airways. - Instruct the SO to - To avoid further effect on open airways. Goal was
 V/s taken make the the dry cough and to partially met.
as follows: environment allergen prevent for high-risk
T- 36.4 free. respiratory tract infection.
P- 91 Dependent: - Medication can relieve
R- 37 - Give medications like airway clearance and may
Sp02- 95% antibiotics, help to remove secretions.
BP- 110/60 bronchodilators, or
inhalants as - It is to clear airway when
prescribed by the there is excessive
physician. excretion.
- Suction nose, mouth,
and trachea as
ordered by the
physician.
 PHILIPPINE ADVENT COLLEGE
RAMON MAGSAYSAY, SINDANGAN, ZAMBOANGA DEL NORTE

NURSING CARE PLAN

Client: Patient X Age: 27 years old Gender: Male Care Plan by:
Address: Tigbao, Sindangan Birthday: July 01, 1995 Religion: RC Date Initiated:
Chief Complaints: Fever, Chills and Vomiting Civil Status: Single

NURSING DIAGNOSIS: acute pain related to localized information as evidenced by persistent cough
ASSESSMENT PLAN OF CARE NURSING RATIONALE EVALUATION
(PLANNING) INTERVENTION
(IMPLEMENTATION)
Subjective: STG: Independent: After 4 hours of
 Mother After 4 hours of - Observe the signs of - Observing for signs may nursing intervention, the
stated nursing intervention, the respiratory distress further evaluate the patient was able to
reduce the coughing
“akong patient will able to reduce like increase patient’s and can prevent
within the shift using
anak kay the coughing within the respiratory rate, further complications. various nursing
sige og ubo shift using various nursing restlessness or use of - To determine if there any interventions, was
maong interventions, ability to accessory muscles. changes in the gas ability to cough out
maglisod cough out phlegm, and - Monitoring the exchange. phlegm, and the client
siyag enable client to verbalize patient’s breathing enabled client to
ginhawa on how to manage cough. verbalize on how to
pattern. - To promote better lung
manage cough. Goal
pero walay - Put the patient in an expansion. was met.
plema”. LTG: upright or high
After 2 days of fowler’s position. - Controlled coughing helps After 2 days of nursing
Objective: nursing intervention, the - Educate the mother to to loosen and remove intervention, the patient
 Heard the patient will be able to instruct the patient to sputum for better airway was slightly able to
child cough have a complete relief pathway. have a complete relief
do the controlled
from cough and maintain from cough and
during cough. maintained clear and
assessment clear and open airways. - Instruct the mother to - To avoid further effect on
open airways. Goal was
 PHILIPPINE ADVENT COLLEGE
RAMON MAGSAYSAY, SINDANGAN, ZAMBOANGA DEL NORTE

 V/s taken make the the dry cough and to partially met.
as follows: environment allergen prevent for high-risk
T- 36.4 free. respiratory tract infection.
P- 91 Dependent: - Medication can relieve
R- 37 - Give medications like airway clearance and may
Sp02- 95% antibiotics, help to remove secretions.
BP- 110/60 bronchodilators, or
inhalants as - It is to clear airway when
prescribed by the there is excessive
physician. excretion.
- Suction nose, mouth,
and trachea as
ordered by the
physician.
 PHILIPPINE ADVENT COLLEGE
RAMON MAGSAYSAY, SINDANGAN, ZAMBOANGA DEL NORTE