Assessmen

Subjective:
Gahagrak
kag
Nabudlaya
n siya
magginha
wa
As
verbalized
by the
grandmoth
er
Objective:
- Abnormal
breathing
sounds:
rales
(crackles)
-Dyspnea
-Choking
or noisy
respiration
s

Diagnosis

Planning

Ineffective
airway
clearance
related to
copious
tracheous
bronchial
secretions

Before the
end of the
shift, the
patient will
be able to
maintain
patent
airway as
evidenced
by:

Intervention

INDEPENDE
NT:
Elevate
head in
moderate to
high bed
rest with the
use of
pillows

>DECREAS
E of
bronchial
secretions
and
>normal
respiration
as
evidenced
by
absence of
dyspnea
and
adventitio
us breath
sounds

Assist in
nebulization
of Ventolin
Salbutamol

Assist in
suction as
indicated

Monitor
oxygen
therapy
DEPENDENT:
Administer
medications
as
indicated:
Ventolin
(Salbutamol/
Nebule)
2.5mg)

Rationale

Doing so
would
lower the
diaphrag
m and
promote
chest
expansio
n,
aeration
of lung
segments
,
mobilizati
on and
expector
ation of
secretion
s.

Key Areas
of
Responsibil
ity

Safe and
quality
nursing
care

Nursing
Theories

Core
Values

Evaluation

Margaret
Jean
Watson:
Philosophy
and
Science of
Caring

Compassio
nate
Service

Goal was
met:

Nebulizer
s and
other
respirator
y therapy
facilitates
liquefacti
on and
expector
ation of
secretion
s.COLLABO
RATIVE
Facilitate
s
liquefacti
on and
removal
of
secretion
s thus
decreasin
g
resistanc
e to
airflow
and
improvin
g oxygen
delivery.
To
prevent
hypoxemi
a

Aids in
reduction
of
bronchos
pasm
and
mobilizati
on of
secretion
s.

NURSING CARE
PLAN FOR PCAP

At the end
of the
shift, the
client was
able to
display
patency of
airway as
manifested
by:
Clients
respiratory
rate is
within
normal
range and
airways is
free of
secretions

Assessm
ent

Diagnosis

Planning

Interventi
on

Objective
:
1m/oimmunoc
omprimis
ed
Laborator
y test:
Presence
of sticky
and
yellowish
secretion
s in
mouth
and nose

Infection
related to
invasion
of
pathogen
s

After the
24 or 48
hours the
client will
Achieve
timely
resolutio
n of
current
infection
without
complicat
ions.

INDEPEN
DENT:
Monitor
temperat
ure

-WBC
Count =
21.2
(Referenc
e value
4.010.15)

Febrile
reactions
are
indicator
s of
continuin
g
presence
of
infection.

IV
regulatio
n

- Chest
Result:
Right
Basal
Pneumon
ia
Lymphoc
ytes =
37%
(Referenc
e value
25% -30
%)
Monocyte
s = 6%
(Referenc
e value
2% 5%)

Rationale

Aseptic
techniqu
e in
performin
g
suctionin
g
(Separate
suction
catheter)
DEPENDE
NT:
Aid in
administ
ering
appropria
te
antimicro
bials:
Antibiotic
s
(Cefotaxi
me)

Rate and
quantity
of
intraveno
us fluid
depends
on
medical
condition
, body
size, and
age.
Regulatio
n ensures
the
correct
amount
of fluid
drips
from the
bag down
the tube
into the
vein at
the
correct
rate.
First-line
defense
against
nosocomi
al
infections
.

To
prevent
emergen
ce of

Key
Areas of
Responsi
bility

Safe and
quality
nursing
care
Managem
ent of
resources
and
environme
nt

Nursing
Theories

Faye
Glenn
Abdellah
s
Concept
of Twenty
One
Nursing
Problems
Jean
Watsons
The
Philosoph
y and
Science
of Caring

Core
Values

Evaluatio
n

Compete
nt
Commitm
ent to
Vincentia
n
Excellenc
e

Goal
Partially
Met:
After the
48 hours,
the client
was able
to exhibit
no
presence
of fever.
Secretion
s is still
present
but not
as
abundant
as
previousl
y
encounte
red

resistanc
e and to
ensure
effective
ness of
the
antimicro
bials

Assessmen
t

Diagnosis

Planning

Interventio
n

Objective:
Dirty and
unkempt
environme
nt:
utensils,
supplies,
and
equipment
scattered
and out of
place
Odorous
smell in
environme
nt

Knowledge
deficit
related to
unsanitary
conditions
at the
bedside
table

After the
end of the
shift the
clients
guardian/f
amily
members
will be
able to
practice
proper
disposal
and
maintenan
ce of the
cleanliness
of their
surroundin
gs

Independe
nt:
Educate
the family
members/
guardian
on
environme
ntal
sanitation

Rationale

Focuse on
changing
and
manipulati
ng the
environme

Educate
the family
members/
guardian
the
importanc
e of
proper air
ventilation
for the
client

nt in order
to put the
patient in
the best
possible
conditions
for nature
to act.

Improve
the ability
to
considere
a clean,
wellventilated,
quiet
environme
nt
essential
for
recovery.

Key Areas
of
Responsibil
ity

Health
education
Manageme
nt of
resources
and
environme
nt

Nursing
Theories

Core
Values

Evaluation

Florence
Nightingal
ess
Environme
ntal
Theory
Faye Glenn
Abdellahs
Concept of
Twenty
One
Nursing
Problems

Competent
Social
Commitme
nt

Goal
Partially
Met:
After the
end of the
shift the
guardian
was able
to
acknowled
ge the
status of
the
sanitation
in their
section
within the
ward and
was able
to
communic
ate and
contribute
in the
ways in
improving
the
condition
of the
environme
nt for the
wellness of
the client.
The
knowledge
was not
relayed to
the other
members
of the
family as
they were
not
present
during the
shift.

Assessme
nt
Subjective:
Wala
kami ka
guha daan
kay wala
kami
kwarta as
verbalized
by the
grandmoth
er.

Diagnosi
s

Planning

Interventi
on

Rationale

Key Areas of
Responsibilit
y

Nursing
Theories

Core Values

Evaluatio
n

Ineffectiv
e coping
related
to
financial
difficultie
s

After the
end of
the shift
the
guardians
of the
client,
particular
ly the
mother,
will be
able to
portray
decrease
of
emotional
distress

Refer to
social
service for
PCSO
assistance

Financial
assistance
can help in
easing
their
financial
burdens

Health
education
Communicatio
n

Hildegard
Peplaus
Interperso
nal
Relations
Theory

Charitable
Compassion
ate

Goal Met:
After the
end of the
shift. The
guardians
of the
client was
able to
display a
decrease
of
emotional
distress
due to
financial
difficulties
and was
able to
discuss
further
with other
members
of the
family on
alternativ
es to be
able to
pay for
the
expenses.

Nursing
Theories

Core
Values

Objective:
-Mother
unemploye
d
-Hospital
bill of
35+K

Educate
home
maintenan
ce and
proper
nutrition
to the
guardian/s

In order to
decrease
risks of
hospitalizat
ion of
family
members
in the
future

-Additional
expenses
for the
post
hospital
order
Husband
income
not
enough

Assessmen
t

Diagnosis

Planning

Interventio
n

Rationale

Key Areas
of
Responsibi

Evaluation

lity
Objective:
-Displayed
Irritability
-Nasal
Congestio
n
Tachypneic
at times

Risk for
aspiration
related to
accumulati
on of
secretions
in the
airways

After the
end of the
shift the
client will
demonstra
te no
incidence
of
aspiration
as
evidenced
by
noiseless
respiration
s , clear
breath
sounds

INDEPEND
ENT:
Encourage
to burp
Maintain
operationa
l suction
equipment
at bedside
Instruct
individual/f
amily
member to
avoid
tight/const
rictive
clothing
that
causes
increase
intraabdominal
pressure
Monitor
Respirator
y rate

Assist in
suctioning,
especially
in the
mouth

Feed in
small
amounts
and in
upright
position

Provide
quick and
accessible
means of
suctioning
if
necessary
Reduces
pressure
on
compromis
ed tissues,
which may
improve
circulation
and
healing
Early
recognitio
n of
breathing
problems
may
prevent
complicati
ons.
Clearance
of
secretions
in the
airways for
proper and
prevent
aspiration
Provides
functional
position
for feeding
and
prevention
of
aspiration

Safe and
quality
nursing care

Faye Glenn
Abdellahs
Concept of
Twenty
One
Nursing
Problems

Compassio
nate
Competent

Goal Met:
After the
end of the
shift the
client
demonstra
te no
evidence
of
aspiration
and was
able to
breathe
clearly and
had
noiseless
respiration
s.