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Nursing Care Plan: Assessment Diagnosis Planning Intervention Rationale Evaluation
Nursing Care Plan: Assessment Diagnosis Planning Intervention Rationale Evaluation
ASSESSMENT
SUBJECTIVE: Marigatan ak makaanges as verbalized by the patient.
DIAGNOSIS
Ineffective breathing pattern related to disease condition (Community Acquired Pneumonia) as manifested by increase respiratory rate.
PLANNING
After 4 hours of nursing intervention client should be able to manifest effective breathing. From 24 breaths per minute to 20.
INTERVENTION
INDEPENDENT Monitor vital signs.
RATIONALE
EVALUATION
Goal partially met.
Client still manifest difficulty of breathing though it is gradually reduces from 24 breaths per minute to 22. Vital Signs: BP 100/70
ASSESSMENT
SUBJECTIVE: Agkakabsut nak, haan ak unay nga makagaraw as verbalized by the patient.
DIAGNOSIS
Activity intolerance related to imbalance between O2 supply and demand as manifested by inability to perform ADL.
PLANNING
After 4 hours of nursing intervention the client will be able to participate willingly in necessary or desired activities.
INTERVENTION
Monitor vital signs.
RATIONALE
To serve as a baseline data.
EVALUATION
Goal met. Client reveals an increase in activity tolerance.
OBJECTIVE: Client is mostly lying on bed. Appears to be weak Unable to perform activities of daily living. Asses potential for physical injury.