Bachelor of Nursing Science

Department of Nursing Science, Faculty of Medicine, University of Malaya

NURSING CARE PLAN

(for students’ assignment) (Revised Aug. 2017)

Date /
Date (the nursing diagnosis identified): 24/5/2022 Nursing
outcome(s)

Nursing diagnosis #1: -

Ineffective breathing pattern related to fluid accumulation due to thoracic empyema as
patient complaint of shortness of breath, tachypnoeic and respiration rate of 34 breaths
per minute.

Objective(s) [S.M.A.R.T criterion]:

1. The patient will maintain optimal breathing pattern as evidenced by relaxed 27/5/2022
breathing, normal respiratory rate at 12-20 and absence of dyspnoea.
2. The patient maintains oxygen saturation at 95-100% and breathing rate at 12-20 31/5/2022
breaths per minute throughout hospitalisation.

Nursing interventions [Prioritised & give rationale (R) for each intervention]
1. Assess respiratory rate, depth and rhythm at least every 4 hours. (I.I) 24/5/2022
R: To detect alterations in breathing patterns to detect early signs of compromise on
respiratory system of the patient.

2. Monitor oxygen saturation using pulse oximetry. (I.I) 24/5/2022

R: To detect problems with oxygenation when oxygen saturation of the patient is less
than 95%.

3. Place the patient in high Fowler’s position. (I.I) 24/5/2022

R: To maximise lung expansion and facilitate breathing of the patient.

4. Administer oxygen therapy 5L/min via nasal prongs as ordered by the doctor. (D.I) 24/5/2022
R: Oxygen therapy corrects hypoxemia which is caused by the fluid accumulation at the
pleural cavity that affects the lung expansion.

5. Encourage the patient to do deep breathing exercises. (I.I) 24/5/2022

R: To enable adequate lung expansion in order to have enough oxygen supply in the
body to prevent shortness of breath.

6. Place the underwater seal drainage bottle below the chest level of the patient. (I.I) 24/5/2022
R: To enable the flow of the accumulated fluid from the patient’s pleural cavity in order
allow the lung to expand normally to supply enough oxygen to the body.

7. Educate chest physiotherapy such as incentive spirometry, postural drainage 24/5/2022

positioning and turning from side to side and chest percussion and vibration to the
patient. (I.I)
R: These techniques will improve lung function and have better breathing which
maintains a patent airway of the patient.

Evaluations:
Goal is met. The patient maintained optimal breathing pattern as evidenced by relaxed 27/5/2022
breathing, normal respiratory rate at 12-20 and absence of dyspnoea.
Goal is met. The patient maintained oxygen saturation at 95-100% and breathing rate at 31/5/2022
12-20 breaths per minute throughout hospitalisation.

Date /
Date (the nursing diagnosis identified): 24/5/2022 Nursing
outcome(s)

Nursing diagnosis #2: -

Hyperthermia related to Bacillus Cereus thoracis empyema infection as evidenced by
patient’s body temperature of 38.3℃.

Objective(s) [S.M.A.R.T criterion]:

1. The patient can maintain afebrile body temperature between 36.0-37.5°C within 24 27/5/2022
hours of hospitalization.
2. The patient can maintain vital signs reading within normal range throughout 31/5/2022
hospitalization.

Nursing interventions [Prioritised & give rationale (R) for each intervention]
1. Assess patient’s general condition and vital signs of the patient. (I.I) 24/5/2022
R: To assist in creating an accurate diagnosis and nursing implementations for the
patient.

2. Monitor the patient's vital signs every 2 hourly especially the tympanic or rectal 24/5/2022
temperature. (I.I)
R: To monitor effectiveness of medical treatment and improve if found ineffective.

3. Monitor fluid intake and urine output of the patient. (I.I) 24/5/2022
R: To identify early if patient is at risk of dehydration since hyperthermia could
imbalance body fluid volume.

4. Remove excessive clothing, blankets, and linens of the patient. (I.I) 24/5/2022
R: To regulate the temperature of the environment and make it more comfortable
for the patient.
5. Administer antipyretic medication such as 1000mg Paracetamol as prescribed by 24/5/2022
the doctor. (D.I)
R: To provide pharmacological therapy to reduce the signs and symptoms of
hyperthermia.

6. Offer a tepid sponging bath to the patient as the body temperature is more than 24/5/2022
38.0℃. (I.I)
R: To facilitate the body in cooling down and to provide comfort to the patient.

7. Start intravenous fluid therapy as prescribed and encourage oral fluid intake 24/5/2022
as recommended by the doctor. (D.I)

R: To prevent imbalanced fluid volume as hyperthermia can lead to dehydration.

Evaluations:
Goal is met. The patient maintained afebrile body temperature between 36.0-37.5°C 27/5/2022
within 24 hours of hospitalization.
Goal is met. The patient maintained vital signs reading within normal range throughout 31/5/2022
hospitalization.

Date /
Date (the nursing diagnosis identified): 24/5/2022 Nursing
outcome(s)

Nursing diagnosis #3: -

Risk for falls related to immobility as evidenced by patient is having poor motor power
of 2/5 at patient’ left and right upper and lower limbs.

Objective(s) [S.M.A.R.T criterion]:

1. The patient is able to have moderate motor power of 3⁄5 at his left and right upper 27/5/2022
and lower limbs.
2. The patient is safe and free from any episode of falls during hospitalisation. 31/5/2022

Nursing interventions [Prioritised & give rationale (R) for each intervention]
1. Assess the patient’s fall risk score using UMMC fall assessment form. The fall risk score 24/5/2022
is 8 which is low risk. (I.I)
R: To collect baseline data to plan appropriate nursing interventions in order to provide
safety to the patient.

2. Place ‘high fall risk’ wrist tag on the patient’s wrist and stick ‘high fall risk’ sticker at 24/5/2022
the patient’s bedside. (I.I.)
R: To alert the nurses that patient has risk to fall.
3. Raise up the bed rails of the patient. (I.I.) 24/5/2022
R: To prevent the patient from falling down from the bed when moving or positioning.

4. Place the patient’s bed at ward which is nearer to the nurse’s counter. (I.I.) 24/5/2022
R: To make sure that the patient is under supervision of nurses and prevent any falls that
can lead to severe injuries.

5. Place the accessories and equipment nearer to the patient. (I.I.) 24/5/2022
R: To make sure the patient can take his accessories easily without any struggles or
tendencies to fall.

6. Put the bed at the lowest level. (I.I.) 24/5/2022

R: To reduce the possibilities to fall and any serious injuries related to fall by lowering
the bed levels.

7. Consult with physiotherapist to provide physical therapy sessions to the patient as 24/5/2022
needed. (C.I.)
R: Frequent exercise will help to improve muscle strength and balance of the patient.

Evaluations:
Goal is met. The patient was able to have moderate motor power of 3⁄5 at his left and 27/5/2022
right upper and lower limbs.
Goal is met. The patient was safe and free from any episode of falls during 31/5/2022
hospitalisation.