SPC Nursing Dept

EXERCISE: WRITING A NURSING CARE PLAN

SCENARIO:
Patient X, 3 years old, female, is admitted to the Holy Child Ward due to fever and cough for three days. Upon initial assessment, her
vitals signs were: T: 38.7oC, RR: 50cpm, HR: 95bpm. She weighs 13.5kg. Her skin is warm to touch, with good turgor.
The patient’s mother reported that the child seems to have lost her appetite and said “She consumed only two spoons of rice, one
small slice of fried chicken and a half glass of milk during breakfast.”
When the nurse talked to the patient, she complained, “My head is aching.” She is irritable and also complained of pain in the chest
when coughing and said, “It’s difficult to breathe.” Her sputum is yellowish in color. Upon auscultation, the nurse heard crackles. She
noted that the patient is using accessory muscles when breathing. She also noted pallor on the patient’s lips and nailbeds.

CLUSTERED DATA NURSING DIAGNOSIS PRIORITY

(Diagnostic Label)
NUTRITIONAL METABOLIC Hyperthermia Medium priority – 2
➢ fever T: 38.7oC ➢ “She consumed only two spoons of
➢ weight 13.5kg rice, one small slice of fried chicken Imbalanced nutrition: less than Medium priority – 3
➢ skin is warm to touch, and a half glass of milk during body requirements
Skin with good turgor breakfast.”

ACTIVITY EXERCISE
➢ cough for three days ➢ pallor on the patient’s lips and Ineffective airway clearance High priority – 1
➢ RR: 50cpm, nailbeds
➢ HR: 95bpm ➢ irritable
➢ pain in the chest ➢ use of accessory muscles when
when coughing breathing
➢ Crackles heard upon ➢ “It’s difficult to breathe.”
auscultation ➢ sputum is yellowish in color

COGNITIVE-PERCEPTUAL Pain Low priority – 4

➢ “My head is aching”

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NURSING CARE PLAN

Name of Patient: Patient X___________________________ Age: _3 y.o__ Ward: Holy Child_______ Bed#: 2__
Chief Complaint: fever and cough for 3 days Diagnosis: ______________________________________________
Physician: Dr. Z__________________________________

Date/ Cues Need Nursing Patient Nursing Implementation Evaluation

Time Diagnosis Outcome Interventions
May Subjective: Activity- Ineffective Within 8 a. Assess rate/depth of 2 Goal partially
11, >pain in the exercise Airway hours, the respirations and chest met. Patient
2020 chest when Clearance patient will movement did not
@ coughing r/t demonstrate R: Tachypnea, shallow complain of
8:00am >client increased effortless respirations and difficulty dyspnea
verbalized: sputum breathing. breathing are frequently Crackles are
“It’s difficult production present because of discomfort still noted
to breathe.” as (You may of moving chest wall and/or upon
evidenced also say: fluid in lungs. auscultation
Objective: by cough, b. Elevate head of bed, change 1
Within 8
>cough for increased position frequently
hours, the
three days respiratory patient will R: This position lowers the
>RR: 50cpm rate and breathe diaphragm, promoting chest
>HR: 95bpm crackles effortlessly. expansion, and mobilization
>sputum and expectoration of
yellowish in R: Effective OR secretions.
color removal of c. Auscultate lung fields, noting 3
secretions Within 8-24
>Crackles hours, the
areas of decreased/ absent
from the
heard upon patient will airflow and adventitious breath
respiratory
auscultation tract depends demonstrate sounds e.g. crackles
>pallor on lips on the clear breath R: Decreased airflow occurs in
and nailbeds integrity of the sound.) areas consolidated with fluid.
> irritable mucociliary Crackles are heard on
>use of transport inspiration or expiration in
system and
accessory the ability to
response to fluid accumulation, (Signed)
cough Name

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muscles when productively. thick secretions and airway

breathing Airway mucus obstruction.
traps inhaled
d. Coordinate with respiratory 7
particulate
toxins and therapist for chest
transports physiotherapy and nebulizer
them out of management as indicated
the lungs by R: Chest physiotherapy includes
means of techniques of postural
ciliary beating
drainage and chest percussion
and cough. A
deficient to mobilize secretions from
mucous smaller airways that cannot be
barrier leaves eliminated by means of
the lungs coughing or suctioning.
vulnerable to e. Suction secretions as indicated 10
injury, and
R: This stimulates or
excessive
mucus or mechanically clears airway in
impaired patient who is unable to do so
clearance because of ineffective cough.
contributes to f. Instruct mother to increase the 4
all common child’s fluid intake. Offer warm
airway
fluids.
diseases.
Dyspnea R: Fluids aid in mobilization
often results and expectoration of secretions
when mucus g. Assist with/ monitor effects of 6
obstructs nebulizer treatments as
airflow by ordered
narrowing the
R: Facilitates liquefication and
‘effective’
airway lumens removal of secretions
within the h. Administer medications as 5
collective indicated: mucolytics,
airway expectorants, bronchodilators,
system. analgesics
Physical signs
of impaired
R: aids in reduction of
mucus bronchospasm as well as

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clearance mobilization of secretions.

include Analgesics are given to
persistent
improve cough efforts by
cough and
bronchial reducing discomfort but should
breath be used cautiously, as they can
sounds. depress respirations.
(Marini & i. Provide supplemental fluids: IV, 9
Formenti, humidified oxygen as indicated
2016)
R: Fluids are required to
replace losses and aid in
mobilization of secretions.
j. Observe strict aspiration 8
precaution.
R: Forceful and continuous
coughing may cause vomiting.
Positioning the patient upright
uses the force of gravity to help
reduce the risk of aspiration.

References:

Marini, J. & Formenti, P. (2016). Pathophysiology and Prevention of Sputum Retention. DOI: 10.1093/med/9780199600830.003.0119
Retrieved on May 23, 2020 from https://oxfordmedicine.com

Herdman, T.H., & Kamitsuru, S. (2018) Nursing Diagnoses Definition and Classifications 2018-2020. 11th Edition. New York: Thieme
Publishers

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