NURSING CARE PLAN:

Cues Nursing Analysis Planning Nursing Rationale Evaluation

Diagnosis Interventions

Subjective: Ineffective airway Microbes enters STG: Dependent Dependent Goal met as
“hindi ako clearance related the lungs and After 3 hrs of Nsg Nursing Nursing evidenced by the
makahinga, to increased colonizes intervention the Intervention: Intervention patient now shows
naninikip na mucus production bronchioles and patient will  Administer  To increase relief in breathing
dibdib ko secondary to alveoli verbalize O2 2-3LPM O2 for cardiac and absence of
kakaubo” as Community understand as prescribed function and dyspnea
verbalized by the Acquired Multiplication of treatment regimen tissue
patient Pneumonia as microbes and to loosen airway perfusion
evidenced by entering of lung
Objective: wheezes and tissue LTG:  Administer  To replace
(+) warm to productive cough After 12 hrs of FWB and blood loss,
touch Inflammatory Nsg intervention PRBC as increase RBC
(+) wheezes response the patient will be prescribed and improve
(+) productive able to show the amount of
Bronchoconstricti relief in breathing O2 in the
cough
on As evidenced by body
(+) O2 therapy absence of
via nasal canula Increase mucus dyspnea  Nebulize the  To loosen
(+) use of secretion patient with build up
accessory combivent as mucus and
muscle Ineffective airway prescribed dilate the
T: 38.2 clearance airways
P: 124
R: 29  Administer  To dilate and
BP: 100/70 Seretide puffs reduce the
and inflammation
corticosteroid of the airways
s such as
hydrocortison
 e as
prescribed

 Perform  To remove
suctioning as secretions.
indicated.

 Hyperoxygen  To reduce the

ate the patient risk of
before hypoxia
suctioning.

Independent Independent
Nursing Nursing
Intervention: Intervention
 Monitor VS  To establish a
baseline data

 Review  To identify
laboratory client at risk,
data such as and promote
CBC, Blood early
typing, Hgt, intervention
Na, K, SGPT,
SGOT, PT,
BUN, and
Crea

 Assist and  May indicate

monitor for evolving heart
client’s report attack
of chest pain

 Keep client on  To decrease

 bed or chair O2
rest in semi- consumption
fowlers and the risk of
position decompensati
on

 Provide quiet  To promote

environment rest

 Explain to the  To provide

patient the information
need for NPO about the
while purpose of the
dyspneic diet

 Health  To provide
teaching education to
emphasizing the client
the need for about his
DM diet, RAI, personal
and other therapy and
medications medications
and to
promote
encouragemen
t of continuity
of care.

Collaborative Collaborative
Nursing Nursing
Intervention: Intervention
 Laboratory  To monitor
test such as the patient’s
CBC, Blood diseases and
typing, Hgt, provide
 Na, K, SGPT, appropriate
SGOT, PT, nursing and
BUN, Crea medical
intervention

 For diagnostic  To assess the

procedure: 2D heart’s size
Echo and shape.
Also to check
how well the
chambers and
valves are
working.

 Blood typing  To ensure the

for BT proper
matching.

 For CP  To assess
evaluation cardiac and
pulmonary
status before
AKA

 Refer to Dr.  To assess the

Dominguez CAP status of
for pulmonary the patient
consult, as and provide
indicated appropriate
care