West Visayas State University

COLLEGE OF NURSING
La Paz, Iloilo City

NURSING CARE PLAN

Name of Patient: RDC Attending Physician: Dr. G
Age: 60 yrs old Ward/Bed Number: MMSW/No .#3 Impression / Diagnosis: Obstructive jaundice secondary to hepatic
mass probably tuberculosis vs. malignancy alcoholic liver cirrhosis

Nursing
Clustered Cues Nursing Diagnosis Rationale Outcome Criteria Rationale Evaluation
Interventions
December 6, 2017 After 5 hours of 1. Assess patient’s 1. To obtain baseline December 6, 2017
5 pm Ineffective Breathing Definition: nursing condition and data and to serve 10.00 pm
pattern related to Inspiration and/or intervention: monitor vital track important
alteration of normal expiration that does not signs and changes. Goal not met;
“Budlay mag
ginhawa kay ga O2:CO2 ratio provide adequate The patient will be record.  The patient did not
gutok akon tiyan” ventilation. able to establish a 2. Auscultate chest 2. To evaluate establish a normal
as verbalized normal, effective presence/character effective respiratory
and assess
pattern as evidence
respiratory pattern airway pattern. of breath sounds
by presence of
as evidenced and secretions respiratory distress;
Objective: Pathophysiology: absence of RR= 37 breaths/min;
 Wheezes heard
during expiration respiratory distress 3. Elevate head of 3. To promote O2 saturation= 96 %
upon Presence of fluid in the bed as physiological and
auscultation on peritoneal cavity will appropriate and psychological ease
all lung fields. result into a blockage of change position of maximal
 RR= 33 air that will enter the of the patient inspiration.
breaths/min diaphragm and thus every 2 hours.
 O2 saturation= producing insufficient air 4. Monitor pulse 4. To verify
96 % needed by the body. oximetry, as maintenance/impro
 Use of accessory
Doenges, et al. (2008). indicated vement in O2
muscles noted
Nurse’s Pocket Guide. saturation.
 11th edition. Philadelphia:
F.A. Davis Company. p.
151.
Nurses Labs (2013)
http://nurseslabs.com/bro
nchial-asthma-nursing-
care-plans/
Student’s Name:
Clinical Instructor:
5. Observe nail 5. To identify
beds, skin and prersence of
color of tongue cyanosis
and mucus
membranes
6. Assist in ADL’s 6. For lesser oxygen
consumption
during activities
7. Demonstrate 7. Aid in increasing
and encourage use oxygen saturation
of deep breathing and will help in
exercises decreasing comfort