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Lester Bautista, age 7, is being treated for pneumonia and difficulty breathing in the pediatric ward. His attending nurse assessed that his symptoms of fever, cough, and breathing issues are likely due to a respiratory condition like bronchitis, which has been exacerbated by his physical deconditioning. His care plan is focused on lessening his breathing difficulties and reducing his fever. The nurse will monitor his vital signs closely, provide supportive care like supplemental oxygen and medication, and help balance rest and activity to aid his recovery. After 8 hours of treatment, Lester's breathing had become more stable and he was able to speak and move more easily.

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Lorlyn Orehuela
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23 views1 page

NCP Layout

Lester Bautista, age 7, is being treated for pneumonia and difficulty breathing in the pediatric ward. His attending nurse assessed that his symptoms of fever, cough, and breathing issues are likely due to a respiratory condition like bronchitis, which has been exacerbated by his physical deconditioning. His care plan is focused on lessening his breathing difficulties and reducing his fever. The nurse will monitor his vital signs closely, provide supportive care like supplemental oxygen and medication, and help balance rest and activity to aid his recovery. After 8 hours of treatment, Lester's breathing had become more stable and he was able to speak and move more easily.

Uploaded by

Lorlyn Orehuela
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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NURSING CARE PLAN

Name of Client: Ceniza, Lester Bautista Age: 7 Sex: Male Room/Ward: 601/ Pediatric Ward
Attending Nurse: Student Nurse Ma. Lorlyn S. Orehuela Date of Care: 03/16/24 Attending Doctor: Dr. J. Rivera

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION


Subjective: “ I have Pneumonia(Bronchitis) To lessen his  Monitor vital and cognitive After 8 hrs. of taking
fever, cough, and also I may be related to difficulty of signs, watching for changes in care of my patient his
have difficulty of respiratory condition blood pressure, heart rate, breathing has become
breathing and his
breathing” (cough, discomfort, and respiratory rate; note stable and he able to
dyspnea), physical fever went down skin pallor and/or cyanosis speak and he can move
deconditioning and presence of confusion too.
(exhaustion,  Provide positive atmosphere  Helps to minimize
Objective: frustration and
interruption in usual while acknowledging the
sleep pattern), possibly difficulty of the situation for rechannel energy
evidenced by the patient
generalized weakness,  Plan care to balance rest  To reduce fatigue
fatigue, exertional periods with activities
dyspnea, and abnormal  Administer supplemental  Type of therapy or
vital sign response to oxygen, medications; prepare medication is
activity. for surgery and other dependent on the
treatments, as indicated underlying
condition and
might include
medications or
surgery to improve
breathing, or
myocardial
perfusion and
systemic
circulation.

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