LORMA COLLEGES CON TEMPLATE

NURSING
CARE PLAN
RELATED LEARNING EXPERIENCE

STUDENT NAME: Castro, Juan Paolo ROTATION:2nd rotation AREA:Oncology Ward

YR LEVEL AND SEC: BSN III- Imogene King DATES: CLINICAL INSTRUCTOR:Ms. Marisol Jomaya

PROBLEM: DIAGNOSIS:
PRIORITIZATION: DATE:

ASSESSMENT NURSING DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective: Ineffective airway Within 8 Monitor respirations and Indicative to After 8 hours of nursing
Patient stated “Inuubo clearance as evidenced hourss of breath sounds,noting rate and respiratory intervention patient stated that he
ako nung nakaraang by Inspiratory and nursing sounds distress is relieved from coughing.
buwan pa, mas lalo na Expiratory wheezes and intervention
pag umaga tapos madali coughing with blood patient will Evaluate cough, amount and To determine
lang ako mahingal agad.” sputum production. feel relief and type of secretions. ability to protect
airway will be airway.
Objective:
cleared Encourage deep breathing
Vital Signs: exercises. To improve
BP: 168/88 breathing and
PR: 76 promote clear
RR: 20 airway
Temp 36.9C Position Head appropriately
for age and condition . To maintain open
-Skin color Good, skin airway in an “at-
warm and dry rest” or
-Inspiratory and compromised
Expiratory wheezes individual

Administer Bronchodilators if
indicated/ Prescribed by the Medication is to
physician. provide
relaaxation in the
lungs and
 widening of
airway for proper
Perform/ assist the client in breathing
learning airway clearance.

Therapies/
modalities may
be required to
acquire and
maintain
adequate airway
clearance.