Patient Anita NCP

St.
Paul University Philippines

Tuguegarao City, Cagayan 3500
School of Nursing and Allied Health Sciences
College of Nursing
Bachelor of Science in Nursing – 3
Second Semester, AY 2021-2022
NURSING CARE PLAN
Name of Student Nurse: Malana, Joshoua B. Civil Status of Patient: Single
Name of Patient: Ms. Anita Tacloban Age: 38 y/o
Date: March 15, 2021 Sex: Female
1. Ineffective Breathing Pattern

CUES/ ASSESSMENT NURSING DIAGNOSIS BACKGROUND GOALS AND OBJECTIVES NURSING EVALUATION
KNOWLEDGE INTERVENTIONS AND
RATIONALE
Objective: Ineffective Breathing Pattern Ineffective breathing pattern is NOC: NIC:
Operative Procedure Done: related to decreased lung defined as an inspiration  Respiratory Status:  Ventilation Assistance
 CTT insertion (R) expansion, secondary to and/or expiration that does Ventilation
 Right lateral empyema and pleural not provide adequate
Thoracotomy under effusion. ventilation. (NANDA GOAL:
VATS International, Inc. Nursing After the nursing intervention,
 Open Deloculation, Diagnoses 11th edition, 2018). the patient will be able to:
Decortication  Manifest and maintain
 Under General The inflammation that caused normal breathing
anesthesia through severe pneumonia damaged pattern and adequate
endotracheal tube. the alveoli and lung tissue, ventilation. With
 (+) shallow breathing altering gas exchange and absence of shallow
after surgery resulting in hypoxemia. As a breathing along with
 Estimated blood loss of result, the blood's oxygen RR (12-16cpm) and PR
900ml supply was reduced, resulting (60-100 bpm) within
St. Paul University Philippines
College of Nursing
in respiratory distress, as normal range.

Vital Signs: manifested by the pt's
 Temp: 37.5 increased work of breathing to
 BP: 115/80mmHg compensate for low oxygen. OBJECTIVES:
 PR: 102 bpm After the nursing intervention, INTERVENTIONS: EVALUATION:
 RR: 22 cpm the patient will be able to: During the health care, the After the evaluation, the
 O2 sat: 98% nurse will: patient was able to:
 Maintain comfortable
ABG Results: and proper  Assist the client in low-  Have an improved
 pH: 7.6 positioning. fowlers position with airway clearance as
 PaO2: 120 mm Hg pillow support and evidenced by RR – 13
 PaCO2: 31 mmHg raise the siderails of cpm and PR – 87 bpm.
 HCO3: 25 mmol/L. the bed. [Allows pt for  Verbalize feeling
better chest expansion, comfortable and
CBC Results: improving breathing secured.
 WBC: 12 (high) by facilitating
 RBC: 3.2 (low) oxygenation to help
 Hemoglobin: 7.5 (low) achieve body’s
 Hematocrit: 35 (low) hemostasis.]
 Neutrophil: .55 (low)
 ALT: 82 (high)  Maintain normal
 Crea: 72 (normal) oxygen status  Maintain O2 via  Normal O2 sat withing
facemask at 5-6L/min the range of ≥ 96%
Subjective: with SpO2 of 98%, as
(-) ordered. [To maintain
adequate oxygenation.]
 Frequently monitory
College of Nursing
the pt’s respiratory

status:
- Changes in O2 sat %  Display normal RR –
- Respiratory Rate 13 cpm and PR – 87
- Pulse Rate bpm.
- Level of  Have a normal LOC
consciousness  Absence of shallow
- Auscultate to assess if breathing as noted
shallow breathing is
still present.
[To prevent hyper or hypo
ventilation of the pt. and detect if
there are changes in respiratory
status that needs immediate
attention.]
 Adhere to non-
pharmacological  Demonstrate and assist
treatments. the pt to perform deep  Execute breathing and
breathing exercise. coughing exercise w/o
[This technique promotes having difficulty.
deep inspiration, which  Execute normal lung
increase oxygenation and expansion and
prevents atelectasis. controlled breathing.
Controlled breathing
methods also aid slow
respirations in
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tachypneic patients.]
 Demonstrate and assist
the pt to perform  Removed excess
coughing exercise. secretion from the
[Enables the pt to help in surgery was noted
breathing and clears the after coughing exercise
lungs by removing was performed.
excess secretion from the
surgery and promote
normal breathing
pattern.]
 Encourage passive
ROM exercises.  Performed passive
[Increasing mobility to ROM without any
help patient return to signs of discomfort.
normal activities as
quickly as possible.]
 Encourage pt to
incorporate adequate  Lessen episodes of
rest periods. [To limit tiredness and SOB
pt from fatigue and
SOB.]
 Provide adequate  Verbalize sense of
ventilation and clean comfort and security in
environment. [To terms of the healing
promote healing environment provided.
environment to the pt
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and ease discomforts.]  Drain 300 ml yellow

 Closely check IFC [To urine output.
monitor the urine output
of pt.]  Drain 100ml
 Closely check JP drain:
- Empty drain: A
general rule-of thumb
is to empty the JP
drain when it is
halfway full. Usually
amounts to 1-2 times
per day.
- Milk JP q 4 hrs.: to
prevent clot formation
in the tubing.
- Secure: Keep the
drain secure and
lowered at the
insertion site so it will
drain proper.  Drain 400ml fluid from
[To monitor shedding of cells and CTT insertion (initial)
body fluids at the surgical site.]
 Closely check bedside
CTT tube [To monitor
fluid drainage and basis
if the pt needs immediate
 Adhere to medication attention.]
College of Nursing
(pharmacological  Follow prescribed

treatment) prescribed pharmacological
by the physician.  Administer post- regimen and was also
operative medications able to state its
such as: importance in her
- Nubain 1mg every 6 current condition.
hours, prn.  Maintained IV fluids.
- Tramadol 50mg every
8 hours as ordered,
started at the OR at
11pm.
- Ketorolac 60mg
alternate with
tramadol every 6
hours.
[To reduce or manage pain and
discomfort felt by the pt. Along
with promoting faster recovery
time.]
 Maintain IV fluids
(PLRS1L x 30 gtts/min
& PNSS1L x 10
gtts/min) [To maintain
pt’s hydration,
electrolyte and blood
levels.]
 Encourage the patient
College of Nursing
to take her prescribed

medication religiously
as prescribed by the
physician. [To help the
patient have a positive
 Verbalize and recall attitude towards
the importance of medications and to help  Elaborate the health
health care regimen improve wellbeing.] care regimen given
provided for her and its importance,
current condition. along with verbalizing
 Explain rationale and the reasons on how it
intended effect of the was able to help in her
nursing care plan. [To current condition.
have a concrete
understanding about the
importance of treatment
program to be displayed
under the current
situation.]
 Recall and assess the
patient’s
understanding about
the overall
intervention. [To
ensure that pt was able
to gasp an
College of Nursing
health teachings and on

how to apply it.]
2. Risk for Infection

College of Nursing
CUES/ ASSESSMENT NURSING DIAGNOSIS BACKGROUND GOALS AND OBJECTIVES NURSING EVALUATION
KNOWLEDGE INTERVENTIONS AND
RATIONALE
Objective: Impaired skin integrity Surgical intervention may be NOC: NIC:
 PNSS1L x 10 gtts/min related to surgical trauma. needed to diagnose or cure a  Tissue Integrity: skin  Infection protection
with an ongoing blood specific disease process, and mucous and wound care:
transfusion of PRBC to correct a deformity, restore a membranes. Closed drainage.
run for 4 hours @ the functional process or reduce GOALS:
left metacarpal vein. the level of dysfunction. After the nursing
 CTT tube connected to Although surgery is generally interventions, the patient will
bedside bottle with an elective or pre-planned, be able to:
initial drainage of 400 potentially life-threatening  Achieve/ Maintain
ml. conditions can arise, requiring timely wound healing
 Jackson pratt drain emergency intervention. without any further
with 100 ml initial (Nurses Labs, 2021) complications such as
output. infection and pain that
 IFC draining well to a Impaired tissue integrity is might interrupt
urine bag with 300ml defined as an altered wound healing.
dark yellow urine epidermis and/ or dermis.
output. (NANDA, 2021-2023) OBJECTIVES: INTERVENTIONS: EVALUATION:
 Estimated blood loss After the nursing During the health care, the After the evaluation, the
of 900ml intervention, the patient will nurse will: patient was able to:
be able to:
Presence of surgical incision:  Prepare and provide  Report being
 CTT insertion (R)  Have a clean and clean, well-ventilated comfortable in the
 Right lateral healthy environment. environment for environment/ isolation
Thoracotomy under isolation. [To provide a area she is in.
College of Nursing
VATS healing environment to

 Open Deloculation, the pt. and free from
Decortication exposure with other
 Under General people to reduce risk of
anesthesia through infection.]
endotracheal tube.
Subjective:  Educate patient about  Elicit understandings

(-)  Have understanding infection control, about infection
about wound care to sterilization, and prevention and
the incision site and aseptic technique control.
how to apply it in procedures. [Promote  Demonstrate proper
maintaining sterility. awareness to the wound care
patient.] techniques and
 Demonstrate and maintain sterility.
discuss the steps in
wound care such as:
1. Wash/ sanitize hands.
2. Remove previous
cover of the wound.
3. Cleanse the outside
part of the wound first
using sterile water.
4. Then clean the inner
part of the wound
using sterile water.
5. Apply betadine (if
College of Nursing
necessary)
6. Apply antibiotic
ointment if necessary.
7. Cover the wound
using sterile gauze
pad (see to it that it
already dried before
covering)
[Established mechanisms
designed to prevent infection and
allow patient to gain
independence towards wound
cleaning.]
 Maintain dependent
gravity drainage of
indwelling catheters,
tubes, and/or positive
pressure of parenteral
or irrigation lines.
[Prevents stasis and
reflux of body fluids.]
 Adhere to facility
infection control,
sterilization, and
aseptic policies and
procedures. [Enables
patient to be aware of
College of Nursing
what should and

shouldn’t be done during
hospital stay,
considering current
condition.]
 Adhere to medication Administer post op  Take the medications

if prescribed by the medications: provided by the
physician along with - Nubain 1amp every 6hrs physician and was
having knowledge PRN able to discuss its
from medication - Tramadol 50mgg, every 8hrs importance to
education. started at OR (11pm) recovery.
- Start ketorolac 60mg  Receive medication at
alternate with tramadol every the right time, in the
6 hrs. right route and with
[Given as administered and be the right dose.
sure to Identify the right patient,
Verify the right medication,
Verify the indication for use,
Calculate the right dose, Make
sure it's the right time, and
Check for the right route to help
in the patients recovery.]
 Encourage the patient
to take her prescribed
medication religiously
College of Nursing
as prescribed by the
physician. [To help the
patient have a positive
attitude towards
medications and to help
improve wellbeing.]
 Monitor CTT tube

 Maintain proper every round to make  CTT tube and JP
functioning and sure it is functioning drains of the patient is
conditioning of correctly. Monitor free from leaks and
drainage tubes. water levels, and fully functional.
output/drainage level,
check for air leaks,
tube patency and free
of kinks or
obstructions. [Keep the
drain secure and lowered
at the insertion site so it
will drain properly.]
 Monitor Jackson Pratt
drain and perform
drain care as per
hospital protocol.
[Keep the drain secure
and lowered at the
College of Nursing
insertion site so it will

drain properly.]
 Encourage patient to
 Understand safety avoid touching,  Remain having an
measures to facilitate rubbing and intact incision site.
timely wound healing scratching the incision,
and other infection and insertion sites.
prevention methods. (Provide gloves or clip
the nails if necessary.)
[Rubbing and scratching
can cause further injury
and delay healing.]
 Encourage sleep and
rest. [Adequate sleep is  Report having a deep
an essential modulator of sleep and verbalized
immune responses. A being well rested.
lack of sleep can weaken
immunity and increased
susceptibility to
infection.]
 Explain rationale and

 Verbalize and recall intended effect of the  Elaborate the health
the importance of nursing care plan. [To care regimen given
College of Nursing
health care regimen have a concrete and its importance,

provided for her understanding about the along with verbalizing
current condition. importance of treatment the reasons on how it
program to be displayed was able to help in her
under the current current condition.
situation.]
 Recall and assess the
patient’s
understanding about
the overall
intervention. [To
ensure that pt was able
to gasp an
health teachings and on
how to apply it.]

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St.

Paul University Philippines

NURSING CARE PLAN

Name of Student Nurse: Malana, Joshoua B. Civil Status of Patient: Single

Name of Patient: Ms. Anita Tacloban Age: 38 y/o

Date: March 15, 2021 Sex: Female

1. Ineffective Breathing Pattern

in respiratory distress, as normal range.

the pt’s respiratory

and ease discomforts.]  Drain 300 ml yellow

(pharmacological  Follow prescribed

to take her prescribed

health teachings and on

2. Risk for Infection

VATS healing environment to

Subjective:  Educate patient about  Elicit understandings

what should and

 Adhere to medication Administer post op  Take the medications

 Monitor CTT tube

insertion site so it will

 Explain rationale and

health care regimen have a concrete and its importance,

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