NURSING CARE PLAN

MASTER PROBLEM LIST

(List the problems in order of PRIORITY)
S
N

PROBLEM*

DAT
E

DA
TE

Shortness of breath

IDENT
3/9/2016

RESO
5/9/2016

Chest pain

3/9/2016

6/9/2016

Inadequate nutrition intake

3/9/2016

Not
resolved
yet

Constipation

5/9/2016

6/9/2016

Immobility

*Problems identified must relate to assessment findings

School of Health Sciences (Nursing) | Master Problem ListP1/Apr2015

NURSING CARE
PLAN
Patient Problem/ Issue 1:
Ineffective breathing pattern due to impaired comfort on the chest

Assessment
Objective data
-Vital signs
-Cyanosis
-Uses of accessory
muscle when
breathing
Subjective data
-Do you have any
chest pain?
-Pain score
-Do you have
difficulty breathing?

Goal &
Expected
Patient will be able
to breath normally
and his SpO2 is at
least 96%

Interventions
(Nurse Does)
-Administer oxygen
-Position Patient in
semi fowler or
fowler position
-Encourage slow
and deep breathing
-Calm patient down

Rationale
(Because)
-Provide patient
sufficient oxygen in
his blood stream

Evaluation (Did
EO happen?)
Patient is able to
breath normally
and maintain his
SpO2 at least 96%

-To promote
oxygenation via
maximum chest
expansion
- Encourages full
oxygen exchanges
in the lungs
-To reduce patient
anxiety due
shortness of
breathe

School of Health Sciences (Nursing) | Care

Plan

Patient Problem/ Issue 2:

Inadequate nutritional intake due to swallowing impairment

Assessment
Objective data
-vital sign
-body weight
-I/o chart
Subjective data
-what kind of food
do you you like?
-do you have loss of
appetite?
-how many cups of
water you drink per
day.

Goal &
Expected
-Ensure nutritional
needs are met

Interventions
(Nurse Does)
-Record and
monitor intake
output chart

Rationale
(Because)
-To measure the
amount of fluids
that enter and exit
the body

-Encourage patient
to eat by giving
small amount of
food

-To regain patient

appetite

-Encourage patient
sips of water

-To replace fluid loss

in the body

-Give patient
protein energy
drinks (eg:
freshlibin)

-To give patient

adequate nutrition
very meal

-Ensure patient is
hydrated
-Ensure patient
have small meals

Evaluation (Did
EO happen?)
-Patient is able to
meet his nutritional
intake
-Patient is hydrated
-Patient is able to
have small meals

Patient Problem/ Issue 3:

Constipation due to immobility

Assessment
Objective data
-I/o chart
Subjective data
-How often do you
open bowel?
-Pain score due to
stomach pain

Goal &
Expected
-Patient will be able
to open bowel
-Patient will be able
to increase fibre
intake
-Patient will be able
to increase water
intake
-Patient will be able
to do simple
exercises

Interventions
(Nurse Does)
-Administer
suppositories
-Education on the
importance of fibre
intake during meals
-Encourage patient
sips of water during
the whole day
-Help patient with
simple ROM/
arrange PT

Rationale
(Because)
-Soften stool which
will facilitate
passing motion
-Soften the stool in
the intestine
-Water will soften
then stool
consistency
-To encourage
physical activity
especially the lower
limbs which will
stimulate bowel
movement

Evaluation (Did
EO happen?)
-Patient is able to
open bowel
-Patients fibre
intake increase
-Patient water
intake will increase
-Patient physical
activity will
increase