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VISION
Governor Panotes Avenue,
“MABINI COLLEGES shall cultivate a CULTURE Daet, Camarines Norte
of EXCELLENCE in education.”
Tel. no. (054) 721-1281 local 109
Email: mabinicollege@hotmail.com
and extension service programs at all educational levels as
its monumental contribution to national and global growth
and development.
Specifically, it transforms students into:
1. God – fearing;
2. Nation – loving;
3. Law abiding;
4. Earth caring;
5. Productive; and
6.Locally and Globally competitive persons

NURSING CARE PLAN

Submitted by:
FONTANILLA, JUAN MIGUEL
BSN IV – B
Group 2
Name: Eden Medino Age: 62 y/o Sex: Female

Assessment Nursing Planning Intervention Rationale Evaluation

Diagnosis
Subjective: Ineffective Goal: Independent: The goal was partially
breathing Establish - Monitor and record - To check and met.
Patient is not able to pattern related spontaneous, non- vital signs reassess vital After 4 hours of nursing
verbalize to impeding labored breathing function changes intervention the patient
pulmonary (respiration).
shows optimal breathing
Objective: congestion d/t Short Term:
pattern as evidenced by
 Deep, fast, noisy impaired GFR After 4 hours of - Assess for lung - To identify extent of
breathing and fluid nursing sounds fluid accumulation in the counts of the patient’s
 Crackles heard on retention or interventions, patient the respiratory respiratory rate from 33
inspiration respiratory will be able to reduce system. cpm to 28 cpm
 Diaphoretic, cold, muscle labored and difficult
clammy skin weakness d/t breathing and
 Unresponsive; may be physical stress. establish a - To facilitate
- Position on
due to fatigue/weakness respiratory rate of gravitational
moderate high back
 Increased respiratory less than 30cpm. expansion of the
rest.
secretions lungs to decrease
 Vital signs taken as Long Term: inspiratory effort.
follows: After 5 days of
 BP= 140/100 mmHg nursing
 PR= 80 bpm interventions, patient
- Maintain calm and - To avoid stressors
 RR= 33 cpm will be able to
non-stimulating and let patient regain
 O2 Sat = 99% demonstrate non-
environment. strength by
 Temperature= 37⁰ labored and manipulation of
spontaneous environment.
breathing.

- Suction secretions - To facilitate airway

PRN. clearance and reduce
effort from DOB.
Collaborative:

- Administer humid - To help patient get

Oxygen (8-!0 Lpm) adequate oxygen
as ordered. despite of DOB.

- Assist in manual - To assist patient on

Ventilation via ET respiration and to
Tube. ensure adequate
tidal volume.
Name: Eden Medino Age: 62 y/o Sex: Female

Assessment Nursing Planning Intervention Rationale Evaluation

Diagnosis
Subjective: Ineffective After 8 hours of Independent: The goal was partially
airway nursing intervention - Auscultate chest for - Noisy respirations met.
“Nahihirapan po akong clearance the patient will character of breath and wheezes are After 8 hours of nursing
huminga ng ayos, naninikip related to maintain optimal sounds and indicative of retained intervention the patient
din po ang dibdib ko,” as restricted breathing pattern as presence of secretions and/or
shows optimal breathing
verbalized by the patient. chest evidence by relaxed secretions. airway obstruction.
pattern as evidenced by
movement as breathing and
Objective: possible noiseless - Assess vital signs, - Changes in these vital the counts of the patient’s
 Persistent dry cough evidenced by respirations. noting any lung signs often indicate respiratory rate from 10
 Dyspnea changes in rate sound, and decrease acute pain and cpm to 19 cpm
 Respiratory depth of breathing. respiration, even if discomfort.
changes patient denies pain.
 Difficulty in breathing
 Vital signs taken as
follows: - Assist patient and - Upright position
 BP= 130/80 mmHg instruct effective favors maximal lung
 PR= 63 bpm deep breathing and expansion and
 RR= 10 cpm coughing with splinting improves
 Temperature= 36.7⁰ upright position the force of cough
(sitting) and effort to mobilize and
splinting of an remove secretions.
incision. Splinting may be
done by the nurse
(placing hands
anteriorly and
posteriorly over chest
wall) and by the
 patient (with pillows)
as strength improves.
- Suction if cough is - “Routine” suctioning
weak or breath increases risk of
sounds not cleared hypoxemia and
by cough effort. mucosal damage.
Avoid deep Deep tracheal
endotracheal or suctioning is
nasotracheal generally
suctioning in contraindicated
pneumonectomy following
patient if possible. pneumonectomy to
Suction the patient reduce the risk of
as needed, and rupture of the
encourage to begin bronchial stump
deep breathing and suture line. If
coughing as soon as suctioning is
possible. unavoidable, it
should be done
gently and only to
induce effective
coughing.

- Encourage oral fluid - Adequate hydration

intake (at least 2500 aids in keeping
mL/day) within secretions loose or
cardiac tolerance. enhances
expectoration.
Collaborative:
- Administer
bronchodilators, - Relieves
expectorants, bronchospasm to
improve airflow.
and/or analgesics as Expectorants
indicated. increase mucus
production and
liquefy and reduce
the viscosity of
secretions,
facilitating removal.
Alleviation of chest
discomfort promotes
cooperation with
breathing exercises
and enhances the
effectiveness of
respiratory therapies.
Name: Eden Medino Age: 62 y/o Sex: Female

Assessment Nursing Planning Intervention Rationale Evaluation

Diagnosis
Subjective: Deficient After the nursing Independent: The goal was met.
knowledge intervention the - Review the disease - Provides knowledge After the nursing
“Hindi ko nap o tanda basta related to lack f client will verbalize process and future base from which intervention the client
ang sabi lang po sa akin baka information understanding of expectations. patient can make verbalized an
raw po ako ay may resources disease process and informed choices
understanding of her
hyperthyroidism eh hindi ko evidenced by potential - Provide information disease process and
naman po alam kung ano request of complications. appropriate to - This information
‘yun,” as verbalized by the additional individual situation.. includes the severity potential complications
patient. informations. of the condition, that arises..
cause, age, and
Objective: concurrent
 Insufficient knowledge complications to
of necessary information determine the course
about her condition of treatment.
 Vital signs taken as
follows:
 BP= 130/80 mmHg - Provide information - A patient who has
 PR= 63 bpm about signs and been treated for
 RR= 10 cpm symptoms of hyperthyroidism
 Temperature= 36.7⁰ hypothyroidism and needs to be aware of
the need for the possible
continuous follow- development of
up care. hypothyroidism,
which can occur
immediately after
treatment or as long
as 5 yr later.
- Discuss drug - Antithyroid
therapy, including medication (either as
the need for primary therapy or in
adhering to the preparation for
regimen, and thyroidectomy)
expected requires adherence
therapeutic and side to a medical regimen
effects. over an extended
period to inhibit
hormone production.
Agranulocytosis is the
most serious side
effect that can occur,
and alternative drugs
may be given if
problems arise.

- Identify signs and - Early identification of

symptoms requiring toxic reactions
medical evaluation: (thiourea therapy)
fever, sore throat, and prompt
and skin eruptions. intervention are
important in
preventing the
development of
agranulocytosis.

- Explain the need to - Antithyroid

check with a medications can
physician and/or affect or be affected
pharmacist before by numerous other
taking other medications,
requiring monitoring
prescribed or OTC of medication levels,
drugs. side effects, and
interactions