NURSING CARE PLAN

GROUP 1
PANGILINAN
TADEO
STA. MARIA
TECSON
RIVERA
SILVESTRE
1st Attempt

ASSESMENT NURSING NURSING GOALS NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTIONS

Subjective Ineffective airway STO: Independent Independent Goals met:

clearance related
to retained
Patient secretions as Within the 8 hours of 1. Assess airway for 1. Maintaining patent airway is always STO:
complained of evidenced by nursing intervention, patency. the first priority, especially in cases
positive sputum The patient was able to
subjective fever, the patient shall: like trauma, acute neurological
cultures maintain normal vital
night sweats, decompensation, or cardiac arrest.
signs, maintain airway
weight loss, 2. Note presence of
2. Unusual appearance of secretions clearance, show the
shortness of Maintain normal vital sputum; evaluate its
may be a result of infection, normal breathing
breath on exertion signs quality, color, amount,
bronchitis, chronic smoking, or other pattern, and
and chest pain odor, and
condition. A discolored sputum is a demonstrate diminished
consistency.
sign of infection; an odor may be chest paint.
Maintain airway present. Dehydration may be present
Method: Interview clearance if patient has labored breathing with
3. Note cough for thick, tenacious secretions that LTO:
efficacy and increase airway resistance.
Objective Show the normal productivity. The patient was able to
breathing pattern 3. Coughing is a mechanism for excrete mucus
clearing secretions. An ineffective secretions and show
SOB 4. Teach the patient the cough compromises airway improved breath sounds
Demonstrate proper ways of clearance and prevents mucus from
Cough being expelled. Respiratory muscle
decrease in chest pain coughing and
Greenish sputum breathing. (e.g., take fatigue, severe bronchospasm, or
prod'n a deep breath, hold thick and tenacious secretions are
LTO: for 2 seconds, and possible causes of ineffective cough.
cough two or three
Sputum test times in succession).
Within 3 days of 4. The most convenient way to remove
result: atypical TB
Nursing Intervention, most secretions is coughing. So, it is
(Mycobacterium
the patient will be able necessary to assist the patient
Avium Complex
to excrete mucus during this activity. Deep breathing,
MAC infxn) secretions and show on the other hand, promotes
improved breath oxygenation before controlled
sounds coughing
HIV negative

Dependent
Method: Dependent
Observation and
Data gathering 1. To improve patient’s health status,
1. Administer remove secretions and promote
medication as per comfort.
doctor’s order.
Collaborative
Collaborative

1. To identify causative/precipitating
1. Submit a sputum factors and to point the
specimen for effectiveness of antimicrobial
culture and agent.
sensitivity testing,
2. To acquire and maintain adequate
as appropriate.
airways and improve respiratory
function and gas exchange.

2. Coordinate with a
respiratory
therapist for chest
physiotherapy and
nebulizer
management as
indicated.
Improved

ASSESMENT NURSING NURSING GOALS NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTIONS

Subjective Ineffective airway STO:

clearance related
Independent Independent
to retained
"Para akong secretions as Within the 8 hours of 1. Assess airway for 1. Maintaining patent airway is Goals met:
hinihingal at evidenced by nursing intervention, patency. always the first priority, especially
nahihirapang shortness of the patient will in cases like trauma, acute
huminga na may breath and maintain a patent neurological decompensation, or STO:
kasamang cough airway clearance, cardiac arrest.
pananakit ng show a normal After 8 hours of nursing
dibdib. Pag 2. Note presence of 2. Unusual appearance of interventions, the
breathing pattern and
umuubo ako ay secretions may be a result of patient was able to
demonstrate sputum; evaluate its
laging may maintain a patent
decrease in chest quality, color, infection, bronchitis, chronic
kasamang kulay airway clearance,
pain amount, odor, and smoking, or other condition. A
berde na plema. showed the normal
Yung timbang ko consistency. discolored sputum is a sign of
na 55kg ay infection; an odor may be present. breathing pattern, and
demonstrated
nabawasan din ng LTO:
5kg simula noong 3. Note cough for 3. Coughing is a mechanism for diminished chest paint.
isang buwan” as Within 2 weeks of
efficacy and clearing secretions. An ineffective
stated by the productivity. cough compromises airway
Nursing Intervention,
patient. clearance and prevents mucus LTO:
the patient will be able
from being expelled.
to excrete mucus After 2 weeks of nursing
Method: Interview secretions and show intervention, the patient
4. Teach the patient the 4. The most convenient way to
improved breath was able to excrete
proper ways of remove most secretions is
sounds mucus secretions and
coughing and coughing. So, it is necessary to
Objective showed improved
breathing. (e.g., take assist the patient during this
SOB breath sounds
a deep breath, hold activity.
Cough for 2 seconds, and
cough two or three
Greenish sputum times in succession).
prod'n
 5. Perform bronchial
tapping by using a 5. This vibration moves the mucus
cupped hand and from smaller airways into larger
Sputum test soft wrists to start ones where it can be coughed up.
result: atypical TB percussion on the
(Mycobacterium side or the back
Avium Complex Dependent
Dependent
MAC infxn)
1. To improve patient’s health
1. Administer
status, remove secretions and
medication as per
promote comfort.
HIV negative doctor’s order such
as bronchodilators
and expectorants
Collaborative
BP: 124/70 Collaborative
PR: 78
RR: 30 1. Submit a sputum
specimen for 1. To identify causative/precipitating
Temp: 37.9 C
culture and factors and to point the
O2 sat: 88% sensitivity testing, effectiveness of antimicrobial
as appropriate. agent.
Weight: 50kg
Height: 5"3 2. Coordinate with a
respiratory
therapist for 2. To acquire and maintain
Method: chest adequate airways and improve
Observation and physiotherapy respiratory function and gas
Data gathering and nebulizer exchange.
management as
indicated.
ASSESSMENT NURSING NURSING GOALS NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTIONS
Subjective Ineffective health STO: Independent Independent Goals met
maintenance related
to insufficient
1. Encourage patient
“Hindi na resources as Within the 4 hrs of 1. Protein and citrus rich foods can STO:
to eat foods that are
Nawala-wala evidenced by cough Nursing help patient to boost immune
rich in protein and After the 4 hrs of Nursing
ubo ko, lagi na with greenish sputum intervention, the system and can help the patient
citrus. intervention, the patient
lang bumabalik. production patient will express to treat easily.
was able to express
Ang bigat ng willingness to
willingness to participate
dibdib dahil sa participate in
2. Assess for related in activities improving
plema. Gusto activities improving 2. Awareness of causative factors
circumstances that health status and was
ko na gumaling health status and provides direction for subsequent
may negatively able to identify
kaso hindi will identify intervention. This may range from
influence resolution necessary health
naman ako necessary health financial constraints to physical
with following the maintenance activities.
maka-bili ng maintenance limitations.
program.
gamut at wala activities.
naman ako pera
pati mga anak LTO:
3. Patients who understand the
ko, di naman 3. Tell the patient
LTO: effectiveness of the suggested After 1 week of Nursing
ako kaya about the
treatment to reduce risk or to Intervention, the patient
sustentuhan”. Within 1 week of advantages of
promote health are more likely to was able to adopt
Nursing adhering to the
Method: engage in it. lifestyle changes
Intervention, the prescribed regimen.
Interview supporting individual
patient will adopt
healthcare goals.
lifestyle changes
Objective 4. To maintain and manage
supporting individual 4. Provide anticipatory
Objective healthcare goals. effective health practices during
guidance
periods of wellness, and identify
SOB ways the client can adapt when
progressive illness/long-term
Cough
health problems occur.
Greenish
sputum prod'n
 5. Teach the patient 5. The most convenient way to
the proper ways of remove most secretions is
Sputum test
coughing and coughing. So, it is necessary to
result: atypical
breathing. (e.g., assist the patient during this
TB
take a deep breath, activity.
(Mycobacterium
hold for 2 seconds,
Avium Complex
and cough two or
MAC infxn)
three times in
succession).

HIV negative Dependent

Dependent
1. Administer
medication as per
BP: 124/70 doctor’s order such 1. To improve patient’s health
PR: 78 as bronchodilators status, remove secretions and
and expectorants promote comfort.
RR: 30
Temp: 37.9 C
Collaborative Collaborative
O2 sat: 88%
1. Refer to social 1. For assistance with financial,
Weight: 50kg services, as housing, or legal concerns (e.g.,
Height: 5"3 indicated. conservatorship).
2. Provide for
communication and
Method: coordination 2. To provide continuation of care
Observation between the and maximize outcomes.
and Data healthcare facility
gathering team and
community
healthcare providers
(Tb dots, Rhu health
services, and etc.)
3. Involve 3. To monitor patient’s condition and
comprehensive establish the specific procedure
specialty health needed by the patient to improve
teams when health status.
indicated (e.g.,
pulmonary,
psychiatric,
enterostomal, IV
therapy, nutritional
support, substance
abuse counselors).

4. Submit a sputum
specimen for culture 4. To identify causative/precipitating
and sensitivity factors and to point the
testing, as effectiveness of antimicrobial
appropriate. agent.

5. Coordinate with a
respiratory therapist 5. To acquire and maintain
for chest adequate airways and improve
physiotherapy and respiratory function and gas
nebulizer exchange.
management as
indicated.