Republic of the Philippines

SULTAN KUDARAT STATE UNIVERSITY

EJC Montilla, City of Tacurong, 9800 Province of Sultan Kudarat

Name of Patient: L.G.L Age:80 Sex: Male

Initial/ Admitting Diagnosis: To Consider Septic Shock Secondary to Community Acquired Pneumonia, High Risk, Rule Out
Cerebrovascular Accident, Bleed

NURSING CARE PLAN

DATE/ ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION
TIME DIAGNOSIS INTERVENTIONS
05/06/2024 Subjective: Ineffective In 10 hours of Independent GOAL
08:30 am “N/A.’’ airway intervention the Intervention: PARTIALLY MET
clearance as client will be able to:
A. Established A. To gain
Objective: evidenced by After 10 hours of
 Productive productive  Maintain rapport to patient trust and intervention the
cough cough, use of airway and the patient’s cooperation. client:
noted accessory patency. relative. B. To  Maintained
 Use of muscles,  Exhibit B. Monitored and establish airway
accessory weak looking, absence or baseline data patency.
facial record vital signs.
muscles reduction of and status of  Still exhibits
noted grimace, congestion C. Assessed patient. congestion
 Weak irritability, with breath airway for patency. in breath
C. Maintaining
looking and difficulty sounds clear, sound.
patent airway
noted of breathing respiration is always the
 Irritability noiseless, first priority,
noted improved especially in
 Difficulty oxygen cases like
of exchanged. trauma, acute
breathing neurological
noted decompensati
on, or cardiac
arrest.
 Republic of the Philippines
SULTAN KUDARAT STATE UNIVERSITY
EJC Montilla, City of Tacurong, 9800 Province of Sultan Kudarat

Dependent
Intervention:
A. To promote
A. Give medication clearance of airway
as prescribed, such secretions and may
as antibiotics, reduce airway
mucolytic agents, resistance.
bronchodilators,
expectorants,
noting
effectiveness and
side effects.

Name of Student Nurse: Hazel Rianne S. Base

 Republic of the Philippines
SULTAN KUDARAT STATE UNIVERSITY
EJC Montilla, City of Tacurong, 9800 Province of Sultan Kudarat

Name of Patient: L.G.L Age:80 Sex: Male

Initial/ Admitting Diagnosis: To Consider Septic Shock Secondary to Community Acquired Pneumonia, High Risk, Rule Out
Cerebrovascular Accident, Bleed

NURSING CARE PLAN

DATE/ ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION
TIME DIAGNOSIS INTERVENTIONS
05/07/2024 Subjective: Risk for In 10 hours of Independent GOAL MET
08:30 am “N/A.’’ impaired skin intervention the Intervention:
integrity client will be able After 10 hours of
A. Established A. To gain trust
Objective: related to to: intervention the
 Prolong prolonged rapport to patient and client:
lying on bed bed rest and  Maintain and the patient’s cooperation.  Maintained
noted decreased Skin relative. B. To establish skin integrity
 Patient’s tissue integrity. baseline data with no new
B. Monitored and
inability to perfusion and status of pressure
record vital signs.
turn to side patient. ulcers.
without C. Inspected skin, C. Skin is at risk
assistance noting bony because of
noted prominences, impaired
 Poor skin presence of edema peripheral
turgor noted circulation,
areas altered
 Watery skin physical
appearance circulation or
obesity. immobility, and
of ulcerated alterations in
skin noted D. Repositioned nutritional
 Generalized patient every 2 status.
weakness
hours.
Noted
Republic of the Philippines
SULTAN KUDARAT STATE UNIVERSITY
EJC Montilla, City of Tacurong, 9800 Province of Sultan Kudarat

E. Kept linens of D. Reduces

bed and mattress pressure on
wrinkle free. tissue,
improving
F. Placed pillow on circulation and
bony prominences reducing time
when patient is any one area is
lying on his back. deprived of full
blood flow.
E. Keeping the
bed wrinkle free
lessens the
probability of
developing
pressure sores.
F. Placing
pillow will
lessen the
pressure in
accumulating
on the bony
prominences.

Dependent
Intervention:

A. Give medication A. To promote

as prescribed, such wound healing on
Vitamin C and clients who do not
 Republic of the Philippines
SULTAN KUDARAT STATE UNIVERSITY
EJC Montilla, City of Tacurong, 9800 Province of Sultan Kudarat

have adequate
Zinc. calories.
B. Pressure ulcers
B. Provided oral cannot heal in
supplementations, clients with severe
tube feedings or malnutrition.
hyperalimentation
to achieve positive
nitrogen balance.

Name of Student Nurse: Hazel Rianne S. Base