CHINESE GENERAL HOSPITAL COLLEGE OF NURSING Nursing Care Plan Patients Name: V.M.M.

Age: 82 Diagnoses: Aspiration Pneumonia

ASSESSMENT

NURSING DIAGNOSIS

INFERENCE

GOAL

INTERVENTION

RATIONALE

EVALUATION

Subjective: Medyo hirap akong gumalaw pagkatapos kong as verbalized by the client Client reports weakness Objective: Fatigue and weakness, Lack of energy, Exertional discomfort Dyspnea Inability to maintain usual routine such as going to the comfort room

Activity Intolerance related to decreased movement

Aspiration Pneumonia

Inflammation of the Lungs

Short term outcomes After 4 hrs of nursing intervention client will 2. Increase exercise display signs and activity levels symptoms of improved gradually. Teach level of activity as methods such as stopping to rest from evidenced by: activity for 3 minutes Display an ease of 3. Plan care to movement carefully balance Report improvement rest periods with in moving activity. Report lessening of weakness. 4. Assist with activities of daily living (ADLs) Long term outcome: and promote After 1 day of nursing exercise, as intervention the client indicated. will display signs and symptoms of total 5. Promote comfort measures and improvement of level of provide for pain and activity as evidenced by: relief such as

Dependent 1. Adjust activities

1. To prevent overexertion 2. To reduce fatigue.

Short term outcomes After 4 hrs of nursing intervention clients goal was met

Impaired Gas Exchange

3. To reduce fatigue

Long term outcome: After 1 day of nursing intervention the clients goal was unmet.

Decreased Tissue Perfusion

4. To protect from activity

Activity Intolerance

5. Enhances sense of well-being and expectation of return to usual activities

divisional activities Independence in like watching tv. moving Increase in 6. Provide maximal movement and be activity within clients able to perform ADLs ability. with ease Reports absence of discomfort when 7. Instruct client or moving. significant others in monitoring clients response to activity and in identifying signs and symptoms. 8. Assist client in learning and demonstrating appropriate safety measures. Collaborative 9. Refer to physical and occupational therapists.

6. Provides normalcy and will help reduce complications associated with immobility 7. Indicate the need to alter activity.

8. To prevent injuries

9. To develop individual exercise program and identify appropriate mobility device Submitted by: Ibasco, Carl S. III A Group 2 N5