 Nursing Care Plan #1- Impaired Breathing pattern – ABG result with oxygenation

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTIO
NS
SUBJECTIVE Ineffective SHORT TERM INDEPENDENT: SHORT TERM:
DATA: breathing pattern GOAL:  Established  To be able to  After 2 hr. of
 The px related to stab rapport gain the px nursing
wound to the left
 After 1 hr. of trust
complained nursing intervention
of some chest in the mid-  Monitored  To assess the goal was
axillary line in the interventions
pain in her vital signs observe met as:
4th intercostal , the px will
left chest every 4 hrs. changes and - the px
space and Hema- have a
and SOB see if it is vital signs
pneumothorax as stable vital
while returning to are:
evidenced by SOB sign
moving from normal BP –
and ABG result.  After 2 hrs.  Positioned  To permits 120/80
the stretcher of nursing
onto the the px into maximum lung TEMP –
interventions semi-fowler’s excursion and 36.6C
examination , the px will
table position chest RR – 20
able to expansion PR –
OBJECTIVE breathe  Observed  To assess if 80bpm
DATA: effectively breathing there are - the px is
 BP – 140/90 without pattern unusual able to
 TEMP- shortness of breathing breathe
37.2C breath patterns that effectively
 RR – 26 may result in LONG TERM:
 PR – 91 Long term goal: an underlying  The goal was
bpm  After 4 hrs. disease met after 4
 The px is of nursing process or hrs. of
awake and interventions  Auscultated dysfunction nursing.
alert , the px ABG  To detect Intervention
breath
throughout result will decreased or because the
sounds
the transport return to adventitious px ABG level
normal state  Taught the px breath sounds decrease
and establish sustained  To help the px into normal
certain limit deep manage state
breathing respiration
techniques
 Monitor ABG
levels every 4
hrs.  To assess if
the px oxygen
DEPENDENT: level is
returning to
 Administered
normal state
 Nursing Care Plan #2 - Pain with pain scale of 8/10 on the operative site

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATI

DIAGNOSIS INTERVENTIONS ON
SUBJECTIVE Acute pain related SHORT TERM INDEPENDENT: SHORT
DATA: to diagnostic GOAL:  Established  To gain the px TERM:
 The px laparoscopy as  After 1 hr. rapport trust
evidenced by px  To see if the VS
 The goal
complained of nursing  Assessed baseline was met
of some pain pain scale of 8/10 intervention. vital signs affected by the
as the px
in her left The px pain pain
pain
chest and scale will  Assessed location,  To ensure the px
scale
SOB while decrease characteristics, receive effective
became
moving from into onset, duration, pain relief
5/10
the stretcher 5/10 frequency, quality
onto the and severity of
examination pain.
 Provided a quiet  To provide
table
environment relaxation for the
 According to
px
the px, she
 Positioned the px  To alleviate the
has a pain
into a comfortable uneasiness of
scale of 8/10
position the px
in operative
site  Asked the px to  To be able to
explain her pain provide better
pain
OBJECTIVE
management
DATA:  To alleviate pain
 Taught the px
 BP – 140/90  To destruct the
relaxing exercise
 TEMP-37.2C px from pain
 Provided music
 RR – 26
therapy
 PR – 91 bpm
 The px is
Dependent:
 To decrease the
awake and  Administered pain
pain felt trough
alert medication as
medications
throughout ordered
the transport

 Nursing Care Plan #3 - Impaired physical mobility due to presence of CTT 1-way bottle.

Assessment Nursing Planning Nursing Rationale evaluation

diagnosis interventions
SUBJECTIVE Impaired physical Short term goal: Independent: The goal was
DATA: mobility related to  After 6 hrs.  Established  To establish the met after 6 hrs.
 The px presence of CTT 1- of nursing rapport px trust of nursing
verbalized way bottle as intervention,  Observed vital  To see if the interventions as
“Nahihirapan evidenced by the px will signs every 3 hrs. physical the px was able
po ako limited movement, able to immobility to learn
gumalaw discomfort and pain learn some affects the VS techniques that
dahil sa scale of 8/10 in the techniques  Positioned the px  To alleviate aid and cope up
nakalagay operative site and cope into a some with some
sakin” up with comfortable discomfort physical
some position activities
OBJECTIVE physical  Determined the  To know what
activities degree of to established
DATA: first when
immobility
 BP – 140/90 assisting
 TEMP-37.2C  To help the px
 Taught the px
 RR – 26 some techniques cope up with
 PR – 91 bpm to regain some the hindrance of
 physical mobility CTT 1-way
without ease bottle
 Provided some  To inform the px
health teachings necessary
such as ROM information and
techniques and assist her
assistance for the needs
px
 Encouraged the  To help the px
family member to established
help the px when physical and
in need of emotional
support support from
family members