NURSING CARE PLAN

NURSING OUTCOME NURSING

ASSESSMENT INTERVENTION RATIONALE EVALUATION
DIAGNOSIS IDENTIFICATION THEORIES
Subjective: To promote Independent Virginia GOAL MET:
- “Budlayan ko Ineffective effective airway • Maintain adequate • Fluids lost by diaphoresis, Henderson’s 14 Patient replied,
mag-ginhawa,” as Airway clearance as hydration. fever, and tachypnea need Components of “Indi naman ah”
verbalized. Clearance evidenced by to be replaced to prevent Nursing Care when asked if
related to eupnea & clear dehydration. it’s still difficult
Objective: broncho- lung sounds within Faye Abdellah’s 21 for him to
• Place patient on High- • Elevation of the thorax
- abnormal lung constriction the shift. Nursing Problems breathe.
Fowler’s position and facilitates lung expansion,
sounds (rales, No abnormal
encourage bed rest. diaphragm contraction and
wheezing) Imogene King’s lung sounds
bed rest promotes bronchial
- chest X-rays Nurse-Patient heard upon
relaxation.
indicate Interactions auscultation.
pulmonary
• Encourage avoidance of • Bronchial irritants further
Respirations
congestion air pollution exposure and aggravate the chronic are regular and
- tachypnea: cessation of smoking. inflammatory process in the the RR is 20
RR – 24 bpm lungs. bpm, within the
- 3 pillow normal range.
orthopnea

Dependent

• Administer Iterax, • Anti-inflammatory drugs

Montiget, and Prednisone reduce inflammation.
 as ordered.

• Administer Ventolin and • Bronchodilators treat

Seretide as ordered. bronchoconstriction and
promote airway clearance.

• Administer Levox and • Antibiotics and antifungals

Diflucan as ordered. treat the infection and
eliminate the cause of
inflammation.

NURSING OUTCOME NURSING

ASSESSMENT INTERVENTION RATIONALE EVALUATION
DIAGNOSIS IDENTIFICATION THEORIES
Objective: Impaired To promote Independent Myra Levine’s GOAL MET:
- shallow and Gas optimal gas • Promote bed rest and • Activities increase oxygen Conservation of Respirations
labored breathing Exchange exchange as decrease activity. consumption. Energy Theory are regular and
 - tachypnea (RR related to evidenced by • Ensure adequate • Air conditioning units give the RR is 20
of 24 bpm) ventilation- eupnea and alert ventilation. If possible, turn off air with lower oxygen Virginia bpm, within the
- restlessness perfusion responsive mental off air conditioning unit concentration than air from Henderson’s 14 normal range.
- Laboratory inequality status within the and open windows. the environment. Components of Patient is alert
results show: shift. Dependent Nursing Care and
Hgb – 123 g/dL conversational.
• Administer Ventolin and • Bronchodilators treat
Hct – 0.37 vol.fr Faye Abdellah’s 21 O2 saturation –
Seretide as ordered. bronchoconstriction and
RBC – 3.96 x Nursing Problems 98.9%
promote airway clearance.
1012/L
Collaborative
O2 Saturation – Florence
92.5% • Administer supplemental • O2 therapy facilitates the Nightingale’s
(all indicating poor oxygen via nasal cannula delivery of adequate O2 to Environmental
oxygenation) at 2 Lpm. the body cells. Theory

NURSING OUTCOME NURSING

ASSESSMENT INTERVENTION RATIONALE EVALUATION
DIAGNOSIS IDENTIFICATION THEORIES
Objective: Ineffective To establish and Independent Betty Neuman’s GOAL MET:
- use of the Breathing maintain an • Teach patient • Helps patient prolong Theory of Systems Patient exhibits
accessory Pattern effective breathing diaphragmatic and expiration time and Stability ease in
muscles of related to pattern as pursed-lip breathing. decreases air trapping. respiration and
 respiration (leans broncho- evidenced by • Encourage rest and • Strenuous activity tires the Lydia Hall’s Core performs
forward and constriction eupnea within the moderation in physical respiratory muscles and and Cure Theory diaphragmatic
elevates shift. activity. causes ineffective breathing when
shoulders when respiration. Faye Abdellah’s 21 feeling short of
breathing) Dependent Nursing Problems breath.
- shallow and Use of
• Administer Ventolin and • Bronchodilators treat
labored breathing Myra Levine’s accessory
Seretide as ordered. bronchoconstriction and
- tachypnea (RR Conservation of muscles of
promote airway clearance,
of 24 bpm) Energy Theory respiration
thus facilitating effective
reduced.
respiration.

NURSING OUTCOME NURSING

ASSESSMENT INTERVENTION RATIONALE EVALUATION
DIAGNOSIS IDENTIFICATION THEORIES
Objective: Self-Care To promote self- Independent Dorothea Orem’s GOAL NOT
- grooming is Deficit care and perform • Teach patient to • This will allow the patient to Self-Care Deficit MET:
poor related to self-care activities coordinate diaphragmatic be more active and to avoid Theory Patient was
- nails are uncut fatigue independently breathing with activity. excessive fatigue or unable to
dirty secondary within the shift. dyspnea during activity. Helen Erickson, perform self-
 - general to increased • Encourage patient to • As condition resolves, Evelyn Tomlin, and care activities
weakness and work of begin to bathe self, dress patient will be able to do Mary Ann Swain’s and continued
fatigue breathing self, walk and drink fluids. more but needs to be Modeling and Role to be
- inability to and Discuss energy encouraged to avoid Modeling Theory dependent on
exert force on insufficient conservation methods. increasing dependence. family members
muscles ventilation Myra Levine’s and nurse.
and Conservation of
oxygenation Energy Theory

NURSING OUTCOME NURSING

ASSESSMENT INTERVENTION RATIONALE EVALUATION
DIAGNOSIS IDENTIFICATION THEORIES
Subjective: Activity To improve Independent Sister Callista GOAL
- “Indi ko kasarang Intolerance tolerance in • Perform Passive ROM • Conditions muscles to Roy’s Adaptation PARTIALLY
pa magbangon,” as related to physical activity exercise every day. activity and prevents Theory MET:
verbalized. fatigue, as evidenced by atrophy. Patient was
hypoxemia participation in Hildegarde able to tolerate
• Provide encouragement • Therapeutic on
Objective: physical exercises Peplau’s passive ROM
and positive feedback on psychological aspect of the
- general within period of Therapeutic exercises but
patient’s efforts. patient and promotes
 weakness and hospitalization. . compliance to the plan of Interaction Process has not
fatigue care. progressed to
- inability to Martha Rodgers’ Active ROM
exert force on • Teach family members • Family members will Theory of exercises yet.
muscles proper rehabilitative continue the plan of care Homeodynamics
- discomfort methods to ensure that after discharge.
during muscles regain maximum
performance strength.
of PROM
exercises

NURSING OUTCOME NURSING

ASSESSMENT INTERVENTION RATIONALE EVALUATION
DIAGNOSIS IDENTIFICATION THEORIES
Risk Factors: Risk for To promote and Independent Sister Callista GOAL
- Patient is Ineffective maintain an • Help the patient develop • Promotes a sense of hope Roy’s Adaptation PARTIALLY
presently Coping optimal level of realistic goals. and accomplishment rather Theory MET:
unemployed related to functioning within tan defeat and Patient has set
due to the the inability period of hopelessness. Betty Neuman’s goals and is
medical to work hospitalization. Health Systems determined to
• Encourage activity to level • Activity reduces tension
condition Stability Theory cope with the
of symptom tolerance. and decreases degree of
- Patient relies illness.
dyspnea as patient
on the monthly Imogine King’s However,
becomes conditioned.
 salary of his • Teach relaxation • Relaxation reduces stress, Theory of Nurse- optimal level of
two eldest techniques. anxiety and dyspnea, and Patient Interactions functioning was
children helps patient cope with not achieved
- Patient disability. Joyce Travelbee’s yet.
verbalized Finding Meaning in
“Kagasto na Illness Theory
gid subong
sang
pangabuhi, na
ospital pa ta.”