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0 Nursing diagnosis and nursing care plan

Assessment Nursing Planning Implementation Evaluation

Diagnosis
Subjective: Ineffective Priority: 1. Establish Goal met.
“I have breathing After 4-5 hours of nursing rapport. Patient
difficulty in pattern intervention Patient will 2. Monitor Vital demonstrated
breathing “as related to manifest signs of Signs and pursed-lip
verbalized by shortness of decreased respiratory record. breathing and
the patient breath. effort and absence of 3. Auscultate diaphragmatic
shortness of breath. breath sounds breathing.
Objective: and assess
•Wheezing Outcomes/Interventions: airway pattern.
upon 1. To gain patient’s trust. 4. Elevate head of
inspiration 2. Track important the bed and
and changes. change to
expiration 3. To check for comfortable
•Shortness of the presence position of the
breath of adventitious breath patient every 2
sounds. hours.
4. To minimize difficulty 5. Encourage
in breathing of patient. deep breathing
5. To maximize effort and coughing
of expectoration. exercises.
6. To decrease 6. Demonstrate
air trapping and diaphragmatic
for efficient breathing. and pursed-lip
7. To prevent situations breathing.
that will aggravate the 7. Encourage
condition. opportunities for
8. To mobilize secretions. rest and limit
physical
activities.
8. Reinforce low
salt, low fat diet
as ordered.
Table 2.1: Ineffective Breathing Rate
Assessment Nursing Planning Implementation Evaluation
Diagnosis
Subjective: Ineffective Priority: 1. Adequately Goal met.
Patient airway After 12 hours of nursing hydrate the Patient’s
claimed that clearance intervention the Patient will patientt. respiratory
he does not related to maintain/improve airway 2. Teach and airways
feels Bronchocons clearance of respiratory encourage the improving.
comfortable triction, distress. use of
with his chest increased diaphragmatic
and feels mucus Outcomes/Interventions: breathing and
pain. production, 1. Systemic hydration coughing
wheezing, keeps secretion moist exercises.
Objective: dyspnoea, and easier to 3. Instruct patient to
•Wheezing and cough expectorate. avoid bronchial
upon 2. These techniques help irritants such as
inspiration to improve ventilation cigarette smoke,
and and mobilize aerosols,
expiration. secretions without extremes hot or
•Dyspnoea. causing cold of
•Chest breathlessness and temperature, and
tightness. fatigue. fumes.
•Suprasternal 3. Bronchial irritants 4. Teach early
retraction. cause signs of infection
•Productive bronchoconstriction that are to be
cough. and increased mucus reported to the
production, which then clinician
interfere with airway immediately.
clearance.
4. Minor respiratory  Increases
infections that are of sputum
no consequence to the production.
person with normal  Change in
lungs can produce colour of
fatal disturbances in sputum.
the lungs of an  Increased
asthmatic person. thickness of
Early recognition is sputum
crucial.  Increased
SOB,
tightness of
chest, or
fatigue
 Increased
coughing
 Fever or
chills
Table 2.2 Ineffective Airway Clearance

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Assessment Nursing Planning Implementation Evaluation
Diagnosis
Subjective: Risk Priority: 1. Assess Goal met.
Patient for Activity After 24 hours of nursing motor function. Patient
verbalized Intolerance. intervention the patient 2. Note contributing participated
that he will participate willingly in factors to fatigue. willingly in
always feels necessary/ desired 3. Ascertain ability necessary/
restless and activities such as deep to stand and desired
fatigue. breathing exercises and move about. activities such
moving exercises. 4. Plan care with as deep
Objective: rest periods breathing
•Immobility Outcomes/Interventions: between exercises and
•Weakness 1. Identify causative activities. moving
•Fatigue factors. 5. Increase exercises.
2. Identify precipitating activity/exercise
factors. gradually such
3. Identify necessity of as assisting the
assistive devices. patient in doing
4. Reduce fatigue. PROM to active
5. Minimizes muscle or full range of
atrophy, promotes motions.
circulation, helps 6. Provide
to prevent adequate rest
contractures. periods.
6. Replenish patient’s 7. Assist client in
energy. doing self-care
7. Promote needs.
independence and 8. Elevate arm and
increase patient’s hand.
activity tolerance. 9. Place knees and
8. Promotes patient’s hips in
venous distention. extended positio
9. Maintains patient’s n.
functional position.
Table 2.3: Risk of Activity Intolerance.

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Assessment Nursing Planning Interventions Evaluation
Diagnosis
Subjective: Anxiety or After 12 hours of nursing 1. Assess Goal met.
Patient fear related intervention the patient emotional Patient
always ask to the on and will understand the or psychological understand the
when he can off Shortness situation and be more factors. situation better,
be of Breath. patience. 2. Explained to the and able to
discharged. patient why he control his
Outcomes/Interventions: needs to wait for anxiety.
Objective: 1. Stress doctor
•Always and/or depression may permission to
wanted to increase the effects discharged.
leave as of illness. 3. Plan care with
soon as 2. Patient will understand rest periods
possible. the risk when the between
•Get upset disease is not treated activities.
when doctor and will be more 4. Assist client in
didn’t give patience. doing self-care
permission to 3. To prevent stress of needs.
discharged. not being able to be
independent and
restless.
4. To promote
independence and
confidence.

Table 2.4: Anxiety or Fear Related to SOB

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Assessment Nursing Planning Interventions Evaluation
Diagnosis
Subjective: Risk of fall Priority: 1. Maintain safe Goal met. Patient
Patient said related to To avoid patient from environment for do not have any
that he needs fatigue and falling down. patient. injury related to
someone or low blood 2. Always falls.
furniture to pressure Outcomes/Interventions: accompany
hold when he showed by 1. To prevent falls. patient when he
wants to go Morse Fall 2. To support the patient wants to walk.
to the toilet. Scale scored when he walks. 3. Suggesting
55(High 3. To prevent patient patient to use
Objective: Risks). from falling backwards wheelchair
•Hold his by using wheelchair. instead of walk.
relatives or 4. Promotes 4. Assist client in
me to go to independence and doing self-care
the toilet. increase activity needs.
•Cannot walk tolerance.
straight.
•Morse Fall
Scale scored
55(High
Risks)
•Low blood
pressure
which is
94/52 mmHg.

Table 2.5: Risk of Fall Related to Fatigue

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