Planning Phase

20

Nursing Care Plan was formulated based on the initial assessment findings of Mr. Good to help him
improve his level of self care performance.
Table 3. Nursing Care Plan
Subjective & Objective

Intervention & Rationale

Cues & Nursing

July 2009

Objectives of

Diagnosis

Criteria

After 10 days of

Ta tormenta yo risulya y

nursing

- Tachycardia, dysrhytmias, & changes in Bp can reflect effect of

nuay puersa myo

intervention the

systematic hypoxemia on cardio function.

kuwerpo, mahina gad yo.

client will be able

Objective:

to:

Difficulty of breathing

Shortness of breath

(+)Cough with bloody

Evaluation

Care

Subjective:

Implementation & Monitoring

1.

2.

Demonstrate

21

22

23

24

25

26

27

28

29

30

The client participates in

treatment regimen such as

Assess respiratory rate, depth. And auscultate breath

sounds.

tinged sputum

Monitor vital signs, pulse oximetry & cardiac rhythm.

breathing exercises,
21

22

23

24

25

26

27

28

29

30

effective coughing & use

Useful in evaluating the degree of distress, &/or chronicity

of oxygen.

of the disease process.

21

22

23

24

25

26

27

28

29

30

improved

3. Elevate head of the bed, assist patient to assume position to

The client manifest

ventilation &

ease work of breathing. Include periods of time in prone position

somehow improved in

Weak muscle strength

adequate

as tolerated. Encourage deep-slow or pursed lip breathing as

ventilation & in his

RR= 35 bpm

oxygenation

tolerated.

breathing.

Pulse-80bpm

of tissues by

- Oxygen delivery maybe improved by upright position &

O2 sat 85%

ABGs or O2

breathing exercises to decrease airway collapse, dyspnea, &

BP140/100mmHg

sat. & be free

work of breathing. Note: recent research supports use of prone

Abnormal ABG

of symptoms

position to increase PaO2.

Pulse rate = 70

of respiratory

Cyanotic nail beds

distress.

- Cyanosis maybe peripheral (noted in nail beds) or central

Participate in

(noted around lips/or earlobes). Duskiness & central cyanosis

Impaired Gas Exchange

treatment

would indicate advanced hypoxemia.

related to ventilation

regimen

perfusion inequality.

within level

-thick, tenacious, copious secretions are a major source of

of ability

impaired gas exchange in small airways.

Nursing Dx:

situation.

21

22

23

24

25

26

27

28

29

30

21

22

23

24

25

26

27

28

29

30

4. Assess/routinely monitor skin & mucous membrane color.

5. Encourage expectoration of sputum.

Subjective & Objective

Cues & Nursing
Diagnosis

Intervention & Rationale

Implementation & Monitoring

July 2009

Objectives of

Evaluation

Care

Criteria
6. Monitor level of consciousness, mental status. Investigate

21

22

23

24

25

26

27

28

29

30

changes.

- Restlessness & anxiety are common manifestation of hypoxia.

7. Evaluate level of activity tolerance. Provide calm, quite

22

23

25

26

28

29

He is able to rest and

manage to prevent &

environment. Limit patients activity or encourage bed /chair rest

control dypneic

during acute phase. Have patient resume activity gradually and

episode.

increase as individually tolerated.

- During severe/acute/refractory respiratory distress the patient
maybe totally unable to perform basic self-care activities because
of hypoxemia and dyspnea. Rest interspersed with care activities
remains an important part of treatment regimen. An exercise
program is aimed at increasing endurance & strength without
causing severe dyspnea, and can enhance sense of well-being.
8. Evaluate sleep patterns, note reports of difficulties & whether
patient feels well rested. Provide quite environment, group

22

24

25

26

24

25

26

28

care/monitoring activities to allow periods of uninterrupted sleep;

limit stimulants e.g., caffeine, encourage position of comfort.
- Multiple external stimuli & presence of dyspnea may prevent
relaxation & inhibit sleep.
9. Administer supplemental O2 judiciously as indicated by ABG
result/O2 sat & patient tolerance.
- may correct/prevent worsening of hypoxia.

21

22

23

27

30

Subjective & Objective

Cues & Nursing Diagnosis

Intervention & Rationale

Implementation & Monitoring

July 2009

Objectives of

Evaluation

Care

Criteria

Subjective:

After 10 days of

Malisud yo risulya sita

nursing

tose dol ta kaba y palta

intervention the

- some degree of bronchospam is present with obstructions in airway &

myo ayre

client will be able

may/may not be manifested in adventitious breath sounds, e.g.

Objective:

to:

scattered, moist crackles ( bronchitis)

adventious breath
sounds, wheezes.

1. Auscultate breath sounds. Note adventitious breath sounds, e.g.,

22

23

24

25

26

27

28

29

30

21

22

23

24

25

26

27

28

29

30

wheezes, crackles, rhonchi.

2. Assess/monitor respiratory rate. Note inspiratory/expiratory ratio.

Maintain

21

Also monitor pulse oximetry.

The client
verbalizes
understanding of

Persistent Cough with

patent airway

- Tachypnea is usually present in some degree & may be pronounced

causes &

mucus production

with breath

on admission or during stress/concurrent acute infectious process.

therapeutic

RR- 35 Pulse-80

sounds

Respirations maybe shallow & rapid with prolonged expiration for

management

Difficulty vocalizing

clear/clearing

comparison to inspiration.

regimen.

Restlessness

Demonstrate

3. Note presence/ degree of dyspnea, e.g., reports of air hunger,

Cyanosis at nail beds.

behaviors to

restlessness, anxiety, respiratory distress, and use of accessory

Chest tightness

improve

- Respiratory dysfunction is variable dependent on stage of chronic

Ineffective Airway

clearance,

process in addition to acute process that precipitated hospitalization,

Clearance related to

e.g., cough-

e.g., infection, allergic reaction.

increased mucus

effectively &

4. Assist the patient to assume position of comfort, e.g., elevates head

production, ineffective

expectorate

of bed, sitting on edge of bed.

cough & broncho

secretions.

pulmonary infection

22

23

22

22

24

25

26

27

23

25

26

27

23

25

27

25

27

28

29

30

muscles.

airway

Nursing Dx:

21

29

- Elevation of the head of the bed facilitates respiratory function by use

of gravity; how ever, the patient in severe distress will seek the position
that most eases breathing. Supporting arms/legs with table, pillows, &
so on helps reduce muscle fatigue & can aid chest expansion.
5. Keep environmental pollution to a minimum, e.g., dust, smoke, &
feather pillows accdg. To individual situation.

30

- Precipitators of allergic type of respiratory reactions that can trigger

onset of acute episode.
6. Encourage/ assist with abdominal or pursed-lip breathing exercises.
- Provides the patient with some means to cope with and control
dyspnea & reduce air-trapping.

21

22

24

29

Subjective & Objective

Cues & Nursing Diagnosis

Intervention & Rationale

Implementation & Monitoring

July 2009

Objectives of

Evaluation

Care

Criteria
7. observe characteristic of cough, e.g. persistent, hacking. Moist.

21

23

25

26

25

26

27

29

30

29

30

Assist with measures to improve effectiveness of cough effort.

- Cough can be persistent but ineffective, especially if the patient is
elderly, acutely ill, or debilitated. Coughing is most effective in an
upright or in a head-down position after chest percussion.
8. Increase fluid intake to 3,000 ml/d with in cardiac tolerance.
Provide warm & tepid liquids. Recommend intake of fluids between,

21

22

23

24

The client is able

to expectorate

instead of during, meals.

secretion readily

- Hydration helps decrease the viscosity of secretions, facilitating

& improves

expectoration. Using warm liquids may decrease bronchospasm. Fluids

oxygen exchange.

during meals can increase gastric distention & pressure on the

diaphragm.
9. Administer medication as indicated.

21

22

23

24

25

26

27

28

29

30

21

22

23

24

25

26

27

28

29

30

- Bronchodilators, relax smooth muscles & reduce local congestion

reducing airway spasm, wheezing, & mucous production.
-antimicrobials; various antimicrobials maybe indicated for control of
respiratory infection/pneumonia.
-analgesics, cough suppressants/institutive; persistent, exhausting
cough may need to be suppressed to conserve energy & permit the
patient to rest.
10. Provide supplemental humidification; nebulizer & breathing
exercise.
-

Humidity

helps

reduce

viscosity

of

secretions

facilitating

expectoration & may reduce, prevent formation of thick mucous plug in

bronchioles.
-breathing exercises help enhance diffusion.

Subjective & Objective

Cues & Nursing Diagnosis

Intervention & Rationale

Implementation & Monitoring

Evaluation

July 2009

Criteria

Objectives of Care
21

23

25

30

Subjective:

After 10 days of

1. Explain / reinforce explanations of individual disease process.

Kere yo puma poko, otro

nursing intervention

Encourage patient/SO to ask questions.

myo risuwelyo.

the client will be

- Decreases anxiety and can lead to improved participation in

understanding

able to:

treatment plan.

of his condition

Shortness of breath

statement of
misconception

difficulty stoping
smoking

Verbalize

effectively, & general conditioning exercises,

23

25

27

30

causative

- Pursed-lip and abdominal/diaphragmatic breathing exercise

factors but

of condition/

strengthen muscles of respiration, help minimize collapse of small

finds hard time

disease process

airways, and provide individual with means to control dyspnea.

to quit

& treatment.

General conditioning exercises increase activity tolerance, muscle

smoking.

Identify

request to smoke

RR= 35 bpm

relationship of

Pulse-80bpm

current

- It is important that the patient understand the difference between

O2 sat 85%

signs/symptoms

nuisance side effects (medication continued), & untoward or adverse

BP140/100mmHg

to the disease

side effects (medication possibly discontinued/changed).

strength, and sense of well-being.

3. Discuss respiratory medications, side effects, adverse reactions.

process &

4. Demonstrate technique using inhaler, such as how to hold it,

Knowledge deficit

correlate these

taking 2-5 minutes between puff, cleaning the inhaler.

regarding condition,

with causative

treatment, self care and

factors.

home needs

and the
21

understanding

Nursing Dx:

verbalizes

2. instruct/ reinforce rationale for breathing exercises, coughing

Objective:

The client

Initiate
necessary

23

22

23

28

29

- Proper administration of drug enhances delivery and effectiveness.

5. Recommend avoidance of sedative anti anxiety agents unless
23

specifically prescribed/approved by physician treating respiratory

condition.

lifestyle

-although the patient may be nervous & feel the need for sedatives,

changes &

these can depress respiratory drive & protective cough mechanism.

participate in

22

6. Stress importance of oral care/dental hygiene.

treatment

- decreases bacterial growth in the mouth, which can lead to

regimen.

pulmonary infections.
7. Discuss individual factors that may aggravate condition, e.g.,

21

22

22

23

27

excessively dry air, wind, environmental temperature extremes,

pollen, tobacco smoke, aerosol sprays, and air pollution. Encourage
patient/ So to explore home.

Subjective & Objective

Intervention & Rationale

Implementation & Monitoring

Evaluation

Cues & Nursing Diagnosis

Objectives of Care

Criteria

July 2009

-These environmental factors can induce/aggravate bronchial

Initiated

irritation leading to increase secretion production and airway

willingness

blockage.

lifestyle

8. Review the harmful effects of smoking and advise cessation of

smoking by patient and/or SO.

changes
21

25

26

29

30

participates

- Cessation of smoking may slow/halt progression of COPD. Even

treatment

when patient wants to stop smoking, support groups and medical

regimen.

monitoring may be needed.

9. Provide information about activity limitations and alternating

22

24

27

28

activities with rest periods to prevent fatigue; ways to conserve

energy during activities (e.g., pulling instead of pushing, sitting
instead of standing while performing task); use pursed-lip
breathing, side lying position.
- having this knowledge can enable patient to make informed
choices/decisions to reduce dyspnea, maximize activity level,
perform most desired activities, and prevent complications.
10. Discuss importance of medical follow -up care, periodic chest
x-rays, sputum cultures.

21

25

- monitoring disease process allows for alterations in therapeutic

regimen to meet changing needs & may help prevent complications.
11. Review oxygen requirements/ dosage for patient who is
discharged on supplemental oxygen. Discuss safe use of oxygen.
- reduce risk of misuse (too little/ too much) and resultant
complications. Promotes environmental/ physical safety.

Subject: Therapeutic Treatment Regimen for Respiratory Disorder COPD & CAP

25

28

30

to

and
in

Time Allotment: 30 minutes

Objective: At the end of the 30 minutes of health teaching, the client will be able to verbalize understanding of the therapeutic treatment regimen and lifestyle
modification appropriate for client with COPD & CAP.

Table 4. Health Teaching Plan

Assessment

Teaching Objective

Content

Teaching Strategy

Evaluation

/Teaching Tool
Subjective:

At the end of 30 minutes

Overview of COPD & CAP the cause & effects on health.

Kere yo puma

health teaching, the client

- COPD Chronic Obstructive Pulmonary Disease- broad classification of disorder including

poko, otro myo

will be able to:

chronic bronchitis, bronchiectasis, emphysema & asthma.. Associated with dyspnea on

risuwelyo.

1. Discuss the disease

exertion & reduced airflow.. Risk factors:

process

Shortness of
breath

statement of

-Air pollution

discussion
Showing
illustration

Asking question: What do

you think is the reason your
experiencing difficulty of
breathing?
Demonstration:
Implementation of

2. Discuss the therapeutic

-CAP (community acquired pneumonia) - inflammatory process of the lung parenchyma

therapeutic management.

management & treatment

commonly cause by infectious agent.

Client performed purse-lip

regimen for COPD & CAP

Therapeutic Management & Lifestyle changes

breathing and assisted by SO

-Instruct breathing exercises (pursed-lip breathing), coughing effectively, expectorate

to position to comfort.

misconcep

Cigarette smoking

Occupational exposure ( coal, cotton, grain)

Objective:

One on one

Observation: The client

tion

3. Initiate lifestyle changes

secretion & avoiding strenuous activities limit activities to with in tolerance to avoid

difficulty stoping

that will help improve his

dyspnea.

religiously complies with

condition

- Proper use of nebulizer &inhaler puff & safety use of oxygen.

medications.

smoking

request to smoke

-Position to comfort side lying, head of bed elevated, sitting at end of the bed or chair.

RR= 35 bpm

- Keep environmental pollution to a minimum, e.g., dust, smoke, & feather pillows

Pulse-80bpm

- Importance of adequate nutrition & balance diet following diabetic diet, increase fluid

O2 sat 85%

intake and enough rest & sleep.

BP140/100mmHg

- Explain health hazard of smoking & importance of smoking cessation.

Nursing Dx:

- Importance of compliance to medication & follow up check up.

Medications: Glibenclamide 3x a day- oral anti diabetic,

Knowledge deficit
regarding condition,

Insulin Novomix 5 units (am & pm)

treatment, self care

Co amoclav 625 mg TID- Penicillin,

and home needs

Seretide 250 mg 2 puffs inhaler ( am & pm)- anti asthmatic & COPD preparation
Combivent inhaler 2 puffs ( am & pm) anti ashthmatic & COPD preparation
Lacipil 2mg( once a day)- calcium antagonist, treatment for hypertention

Implementation Phase

The 10 days monitoring and recording of nursing care plan implementation of Mr. Good from July 21 to July 30,
2009.
Table 5. Monitoring Chart
Nursing Diagnosis

July 21, 2009

1. Impaired Gas

Monitor vital signs, note

tachycardia, O2 sat.
Assisted/teach client how to
position in comfort

Exchange related to

Client participated in position

to comfort, side lying , turn to
sides & head of bed elevated

July 21, 2009

2. Ineffective Airway

Clearance related to

Auscultated breath sounds,

wheezes.
Monitored V/S, dyspnea

increased mucus

July 26, 2009

production,
ineffective cough &

July 23, 2009

July 24, 2009

Encouraged pursed-lip
breathing & expectorate
sputum.
Monitored cyanosis in nail
beds.

Monitored level of mental

status. Observe
changes. Rendered
oxygen as needed.

Client perform deep breathing

exercise & rest

July 27, 2009

July 28, 2009

July 29, 2009

Adequate fluid intake

encouraged.
Imparted knowledge about
present condition.

Provided calm & quite

environment & minimize
dust etc. Kept rested.

Client verbalized
understanding of health care
needs
Encouraged client to continue
with therapeutic
management.

July 22, 2009

July 23, 2009

July 24, 2009

July 26, 2009

ventilation perfusion
inequality.

July 22, 2009

Advised cessation of
smoking.

broncho pulmonary

Encouraged pursed-lip
breathing
Head of bed elevated
Positioned to comfort.

Encourage coughing
exercise &
expectorate
sputum.

July 27, 2009

Increase fluid with in cardiac
tolerance & comply
with medications

Nebulized with assistant.

Deep breathing
exercises
Praise for following regimen

July 28, 2009

Nebulized with deep
breathing.

3. Knowledge deficit
regarding condition,
treatment, self care
and home needs

Allow

client to express
concern.
Client stated wanted to go out
of room & have a stick
of cigarette.

July 26, 2009

Discuss factors that can
aggravate condition.

July 22, 2009

Assess

clients level of
understanding.
Explain client the disease
process & health hazard
of smoking.

July 27, 2009

Reinforce rationale for breathing
exercises, coughing effectively &
limit activity with in tolerance.

Recommend
avoidance
use of sedative &
anxiety agents.

July 28, 2009

Discuss safe use of
oxygen.

July 30, 2009

Demonstrate improving
ventilation & oxygenation by
lessening symptoms of
respiratory distress.

July 25, 2009

Limit activity with in
tolerance. Stress
importance of rest.

July 30, 2009

Client comprehends self-care

needs.

Client able to expectorate

secretion & improved
oxygen exchange.
Praised client.

July 24, 2009

July 25, 2009

July 23, 2009

Limit client activity

Encouraged bed/chair rest.

July 29, 2009

infection

July 21, 2009

July 25, 2009

Discuss respiratory
medication side effects &
adverse reaction
(medication
continued/discontinued)

Demonstrate technique in
breathing exercise & using
inhaler.

July 29, 2009

July 30, 2009

Client realized importance of

self care & treatment.

Client agreed with self care &

cessation of smoking.

Evaluation Phase
Below is the final assessment result of Mr. Good utilizing the same Assessment Tool for
the final evaluation of the level of self-care performance.
Table 6. Final Assessment of Mr. Good
Assessment Parameters

No.
of
Items

Perfect
Score

Clients
Score

Mean
Score

Description

I. Universal self-care
requisites
II. Developmental
self-care requisites
III. Health Deviation
Self-care requisites
Total

19

76

43

2.3

Average

20

10

Below Average

24

20

3.3

High

30

120

73

2.5

Average

The table shows that Universal self-care requisites has a mean score of 2.3 which is
average. Followed by developmental self-care requisites with a mean score of 2 described as
below average self-care performance. And lastly, Health deviation self care requisites is with a
mean score of 3.3 which is described as high in self-care performance.
2. 5
0

LOW

BELOW AVERAGE

AVERAGE

HIGH

Figure 5. Final Assessment of Mr. Good on the Level of Self-care Performance

Interpretation
The final assessment of Mr. Good has a total score of 73. The mean score were added and
divided by the total number of categories is equal to 2.5 as an overall mean score described as an
average level of self-care performance as demonstrated on the scale.
Table 7. Comparative result of initial and final assessment of Mr. Good level of self- care
performance

Assessment
Parameters
I. Universal self-care
requisites
II. Developmental
self-care requisites
III. Health Deviation
Self-care requisites
Total

No. Perfect Clients Mean Description Clients Mean Description

of
Score
Score Score
Score Score
Items
19
76
25
1.3
Below
43
2.3
Average
Average
5
20
7
1.4
Below
10
2
Below
Average
Average
6
24
9
1.5
Below
20
3.3
Average
High
30
120
41
1.4
Below
73
2.5
Average
Average

2.5

1.4

LOW

BELOW AVERAGE

AVERAGE

HIGH

Figure 6. Comparative Result of the Initial & Final Assessment of Mr. Good level of self-care
performance

FINDINGS
Initial and final assessment was conducted to a client with COPD & CAP through
utilization of questionnaire checklist assessment tool of Orems self care deficit theory. The
client was assessed within three self-care assessment parameters specifically universal self-care
requisites which deals with life process functioning, developmental self-care requisites which
deals with condition or associated with events and health deviation self-care requisites which
includes seeking & securing appropriate medical assistance. The results of the assessment were
computed statistically & mean score was analyzed and interpreted well.
The initial assessment of the client showed a below average self-care performance
with a total mean score of 1.4. Out of 120 total perfect score of all items, the client gathered only
41 total clients score. This described as below average self-care performance. Through the
result of the initial assessment, three problems were prioritized in the nursing care plan. These
problems identified where Impaired Gas Exchange related to ventilation perfusion inequality,
Ineffective Airway Clearance related to increased mucus production, ineffective cough &
broncho pulmonary infection and Knowledge deficit regarding condition, treatment, self care and
home needs. The nursing care plan was implemented from July 21 to July 30.
Implementation of nursing care plan caused improvement in clients self care
performance as shown in the final assessment conducted after nursing interventions &
implementation. Using the same assessment tool as of initial assessment, clients self-care
performance improved from initial assessment 1.4 total mean score ( below average) to 2.5 total
mean score ( average) final assessment . The client made a difference of 1.1 in self-care
performance.

CONCLUSION
The findings obtained indicate that utilization of Orems Theory is beneficial for
client with specific disorder particularly client who has a problem with self-care, it also benefited
the significant others of client who assisted in the care and nurses as well who initiated and

implemented effective nursing intervention in the care of client. The aim of attaining increase
level of self-care performance for the client with COPD & CAP was achieve by utilizing Orems
Theory as s guide in nursing process. More over, based on the findings there is significant
positive change in clients self-care level of performance when Orems Theory was utilized in
the nursing process.

RECOMMENDATION

Based on the findings and conclusion, the nurse highly recommends the
application of Orems self care deficit theory in the care of clients or patients with specific
disorder specifically clients with poor self-care performance. By utilizing Orems self care
deficit theory in nursing process, the more quality care can be rendered to a client that
contributes to his/her health improvement. And lastly, Orems theory could also leads to a better
nursing care outcome when implemented well.