VII.
NURSING CARE PLAN
ASSESSMENT DATA NURSING DIAGNOSIS GOALS AND NURSING INTERVENTIONS AND EVALUATION
(Problem and Etiology) OBJECTIVES RATIONALE
(Subjective & Objective Cues)
Subjective: Ineffective airway Short term goal: INDEPENDENT: Short term
clearance related to goal:
“ galisod siya ug storya tungod retained of secretions After 15 minutes of Provided chest physiotherapy after
saiyang ubo “ as verbalized by thorough nursing nebulization. Goals met. After
the son intervention the patient R: to remove the mucus 15 minutes of
will be able to: secretions in the airways thorough
nursing
a. gradually
Objective: expectorate Encouraged deep breathing and intervention, the
coughing exercises as indicated client was able
retained
R: to strengthen respiratory to gradually
- Presence of crackles secretions expectorate
muscles
upon auscultation b. demonstrate retained
various strategies secretions and
to gradually Encouraged and assisted with demonstrated
- non-productive cough abdominal or pursed-lip breathing
achieve an
effective airway. R: Provide patient with some various
means to cope with/control strategies to
- difficulty vocalizing gradually
dyspnea and reduce air-trapping.
achieve an
Long term goal: effective airway.
After 2 days of thorough DEPENDENT: Long term
nursing interventions, goal:
the patient will achieve Nebulization (Combivent: 1 neb +
totally effective airway budesonide: ½ neb) done as Goals met. After
ordered. 2 days of
clearance through
R: to manage reversible thorough
complete expectoration nursing
bronchospasm associated w/
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VII. NURSING CARE PLAN
of retained secretions. obstructive airway diseases in interventions,
patients who require more than a the patient was
single bronchodilator. able to achieve
totally effective
Administered low flow oxygen airway
therapy (2L/min) via nasal cannula clearance
as ordered. through
R: to decrease hypoxemia complete
expectoration of
retained
secretions.
POTENTIAL INTERVENTIONS
Dependent
Suction secretions
R: to clear airway when excessive
secretions are blocking airway.
ASSESSMENT DATA NURSING DIAGNOSIS GOALS AND NURSING INTERVENTIONS AND EVALUATION
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VII. NURSING CARE PLAN
(Problem and Etiology) OBJECTIVES RATIONALE
(Subjective & Objective Cues)
Subjective: Activity Intolerance (Level Short term Goals: INDEPENDENT: Short term
3) related to imbalance Goals:
“dili kayo ko kalihok..” as between oxygen supply After 2hours of thorough 1. Assisted patient in bed to chair
verbalized by the patient. nursing intervention, the and/or wheelchair mobility. Goals met. After
and demand
client will be able to: R: To prevent injuries 30 minutes of
thorough
Objective: a. Improve heart 2. Assisted patient in passive ROM nursing
rate from 105bpm exercises. intervention, the
- Abnormal decrease of - 100bpm R: to promote venous return client was able
RBC 3.96 b. Use identified to improve heart
- Abnormal decrease of techniques to 3. Positioned client in Semi-fowler’s rate from 105
hemoglobin 11.3 enhance assistive position. bpm to 100bpm
- Abnormal decrease of mobility. R: to promote proper lung and Used
hematocrit 34.0 expansion. To maximize oxygenation for identified
- pale skin cellular uptake techniques to
- Heart Rate: 105 bpm enhance activity
4. Encouraged rest periods for client intolerance.
and avoid exertion on unnecessary
activities.
R: to conserve energy
consumption.
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VII. NURSING CARE PLAN
ASSESSMENT DATA NURSING DIAGNOSIS GOALS AND NURSING INTERVENTIONS AND EVALUATION
(Problem and Etiology) OBJECTIVES RATIONALE
(Subjective & Objective Cues)
Subjective: Ineffective tissue perfusion Short Term: ACTUAL INTERVENTIONS Short term
(GI) related to interruption goals:
“galisod ko ug libang… “ as of arterial blood flow At the end of 3 hours of INDEPENDENT:
verbalized by the patient. nursing interventions, Goals met. At
the patient will be able 1. Assisted client in performing range of the end of 3
to: motion. hours of nursing
Objective: R – to promote venous return interventions,
a. Improve blood the patient was
> Absent bowel sounds pressure from 2. Provide small/easily digested food and able to Improve
70/40 mmHg to fluids as tolerated. blood pressure
> Melena 130/70mm Hg R – not to overwhelm the integrity of the from 70/40
GI with the presence of food and to mmHg to
> Altered blood pressure - b. Demonstrate allow blood flow. 130/70mm Hg
70/40mmHg various strategies and
to improve tissue 3. Encourage rest after meals Demonstrate
perfusion going to R: To maximize blood flow to stomach various
the GI. enhancing digestion. strategies to
improve tissue
Long Term: 4. Elevate the extremities of the patient perfusion going
within the cardiac reserve to the GI.
At the end of 24 hours of R – to allow venous return
nursing interventions, Long term
the patient will be able DEPENDENT: Goals
to:
1. Administer dopamine via IV 14cc/hr. Goals met. At
a. maintain normal R – to improve tissue perfusion through the end of 24
blood pressure correcting hypotension. hours of nursing
within the normal interventions,
range POTENTIAL INTERVENTIONS: the patient was
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VII. NURSING CARE PLAN
b. Establish bowel able to maintain
sounds. 1. Prepare Client for Nasogastric insertion normal blood
R – for decompression of the GI. pressure within
the normal
range and
COLLABORATIVE: establish bowel
sounds.
1. Refer to nutritionist: Imbalanced
Nutrition, less than body requirements.
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