Nursing Care Plan (actual)

Impaired Gas Exchange

Cues Nursing Scientific Objective/ Implementatio Rationale Expected

Diagnosis Explanation Planning n Outcome
Impaired gas Due to the
Subjective: exchange damage of the Short Term: Establish rapport. To build trusting Short Term:
“Nahihirapan related to alveolar capillary relationship.
akong huminga alveolar membrane After 2-3 hrs. of After 2 hrs. of
paminsan-minsan”, capillary causes N.I, the pt will Monitor and To have N.I, the client
as the pt. verbalize membrane decrease ability verbalize record V/S. baseline data. shall return
destruction. of the alveoli to understanding of demonstrate
Objective: perform gas causative factors breathing
exchange, due and appropriate techniques.
Received pt. on hi- to this there will intervention.
fowler’s position, be decrease
conscious and oxygen supply in Maintain patent Position the pt. in To maintain
coherent, with all body parts, airway. semi fowler’s airway.
ongoing O2 via w/c the cell position.
nasal cannula needs to
regulated @ 2 function well.
LPM, with ongoing
D5W 1L regulated Encourage Promote optimal
@ 10-15 gtts/min. frequent position chest expansion
@ 780 ml. level changes and and drainage of
infusing well @ deep breathing/ secretions.
right metacarpal coughing exercise
vein.
 (+) DOB Maintain Instruct pt. to For mobilization
 (+) chest adequate Input increase water of secretions but
pain (pain and Output. intake. avoid fluid
scale 8/10) overload.
 (+) Body

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 weakness Long Term:
 (+) Long Term:
Wheezing After 3-4 days of
upon N.I, the pt. will After 2 days of
auscultation learn ways on N.I the client
 (+) pale due how to improved shall be free
to hypoxia ventilation and from any
 (+) tapioca- adequate respiratory
like plug oxygenation. distress.
 (+) Barrel
chest
Maintain good Keep To reduce
and relaxing environment irritant effect on
Vital Signs:
environment. allergen/ pollutant airways.
RR: 27cpm
free.
(tachypnea)
Discuss To promote
PR: 102 bpm
implications of prevention/
(tachycardia)
smoking related management of
to the illness/ risk.
condition.

Encourage client To improved

to stop smoking, lung function.
attend, cessation
program as
necessary.

Encourage Helps limit

adequate rest and oxygen needs/
limit activities to consumption.
within client
tolerance.

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 Identify specific To facilitate
supplier for independence.
supplemental
oxygen necessary
respiratory
device, as well as
other individually
appropriate
resource.

Provide To aid
supplemental respiratory
oxygen at lowest difficulty.
concentration and
monitor carbon
dioxide narcosis.

Maintain Provide To promote

medications on medications on wellness.
time. time.

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 Nursing Care Plans (actual)
Activity Intolerance

Cues Nursing Scientific Objective/ Implementatio Rationale Expected

Diagnosis Explanation Planning n Outcome
Activity Inadequate
Subjective: Intolerance oxygen in the Short Term: Establish rapport. To build trusting Short Term:
“Hindi ako related to circulation can After 3-4 hrs. of relationship. After 3-4 hrs. of
makatayo, imbalance develop N.I, the patient N.I the pt. shall
hinihingal ako ”, as between oxygen weakness in our and family Monitor and To have returned to
the pt. verbalize supply and muscles. members will record V/S. baseline data. normal activity
demand, Muscles need understand and and exercise
Objective: possibly oxygen to move comply with levels, taking
evidence by and to do its prescribed into account
Received pt. on hi- weakness and function. If the therapeutic extent of cardiac
fowler’s position, exertional patient cannot regimen. damage.
conscious and dyspnea. tolerate any
coherent with activities
ongoing O2 via because of the Maintain good Note client report To reduce
nasal cannula low oxygenation and organize of weakness, possibility of
regulated @ 2 caused by the activity fatigue, pain, fatigue.
LPM, with ongoing ventilation- difficulty
D5W 1L regulated perfusion accomplishing
@ 10-15 gtts/min. imbalance task and/or
@ 780 ml. level caused by the insomnia.
infusing well @ pathological Long Term:
right metacarpal minimized lung Long Term:
vein. expansion. After 2 days of After 2 days of
 (+) DOB N.I, the pt. will N.I the client
 (+) chest learn techniques shall be free
pain (pain on how to limit from any
scale 8/10) respiratory respiratory
 (+) Body distress. distress.

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 weakness
 (+) Maintain Increase To ascertain
Wheezing adequate rest. exercise/ activity participation.
upon levels gradually,
auscultation teach methods
 (+) pale due such as stopping
to hypoxia to rest for about 3
 (+) tapioca- min. during a 10
like plug min. walk.
 Barrel chest
Sitting down To conserve
instead of energy.
Vital Signs: standing to brush
RR: 27cpm. hair.
(tachypnea)
Plan care with To avoid fatigue.
PR: 102 bpm. rest periods
(tachycardia) between
activities.

Provide positive Helps to

atmosphere, minimize
while frustration,
acknowledging rechanneled
difficulty of the energy.
situation for the
client.

Instruct client/SO To indicate need

in monitoring to alter activity
response to level.
activity and in
recognizing signs
and symptoms.

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 Give client To sustain
information that motivation.
provides
evidences of
daily/ weekly
progress.

Assist client in To prevent

learning and injuries.
demonstrating
appropriate safety
measures.

Maintain Provide To promote

medications on medications on wellness.
time. time.

35
 Nursing Care Plan (potential)
Risk for Infection

Cues Nursing Scientific Objective/ Implementation Rationale Expected

Diagnosis Explanation Planning Outcome

Subjectives: Risk for infection Due to the Short Term: Short Term:
related to retain presence of Establish rapport. To build
secretions in the secretions and After 2hrs. of N.I, trusting After 2 hrs. of N.I
lung. blockage of the client will relationship. the pt. shall
airways, verbalize demonstrate
Objective: microorganism understanding Monitor and record To have proper
will likely to and techniques V/S. baseline data. understanding
Received pt. on hi- grow on moist, on how to avoid and techniques to
fowler’s position, dark and warm or reduce eliminate the
conscious and area. infections. cause of infection.
coherent, with
ongoing O2 via Maintain Encourage early To reduce to
nasal cannula mobilization of ambulation, deep risk of existing
regulated @ 2 respiratory breathing exercise factors.
LPM, with ongoing secretions. coughing and
D5W 1L regulated position change.
@ 10-15 gtts/min.
@ 780 ml. level Educate the proper To prevent
infusing well @ use of tissue when contamination.
right metacarpal coughing or
vein. sneezing and
proper disposing.

Teach the pt’s To prevent the

relative about spread of the
proper hand infection.

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 washing.

Avoid cigarette To prevent the

smoking. worsening of
the disease.

Instruct the pt. to To loosen the

increase fluid secretions.
intake.
Long Term:
Long Term:
After 3 days of N.I
After 2 days of the pt. shall be
N.I the client will free from any
learn techniques infection.
and prevention
of the infection.

Maintain clean Provide comfort To eliminate

and safety and safety. weakness and
environment. promote
energy.

Maintain nutritional To boost the

needs like fruits immune
and vegetables. system.

Medication Discuss the aid of To promote

compliance on taking antibiotics as wellness.
time. directed.

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