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Nursing Care Plans

NURSING
ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

Subjective: Ineffective Short Term: Independent : GOALS MET

“Nahihirapan akong breathing pattern Within 10-15 1. Elevated the head of the 1. Provides maximum lung
huminga”, as stated by related to minutes of nursing bed, placed in an upright expansion.
the patient decreased lung interventions, the position.
expansion client’s respiratory
Objective: rate will decrease 2. Instructed pursed-lip 2. To increase oxygen intake
 Restlessness from 35-25 cpm breathing. and increase release of Carbon
 Rapid shallow dioxide.
breathing Long Term:
 Distended neck 3. Kept the room well 3. A well ventilated
veins After 8 hours of ventilated.
environment contributes to
 Tactile fremitus nursing
sufficient air circulation.
decreased and interventions, the
breath sounds client’s breathing 3. Assessed chest tube
decreased pattern will be drainage system for the
 RR = 35 cpm normal in rate and following:
 PR=126 rhythm within the 8
 Cyanosis hrs shift. -Secure connection
- A loose connection can allow
 CTT at the Right
air entry and positive pressure
in the intrapleural space
resulting in further lung
collapse.

-Kept chest drainage system

below level of chest - This allows mobility while
preventing accidental knock
over of the system.

-Intact water seal -This prevents air entry into


-Presence of air leak or
bubbling in the water seal
Dependent:
1. Administered supplemental
oxygen at 2-3 LPM by
cannula as indicated
Collaborative:
1. Reviewed chest x-ray reports
and laboratory studies as
indicated.
the intrapleural space.
can indicate clogged or kinked
tube.
1. Enhances oxygen delivery to
the lungs for circulatory
uptake, especially in presence
of reduced ventilation.
1.) Monitors effectiveness of
respiratory therapy and
documents developing
complications.
 NURSING
ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

Subjective: Ineffective tissue Short Term: Independent : GOALS MET

“Nahihirapan siyang perfusion related Within 30 minutes of 1. Administered oxygen at  This saturates
huminga tapos to decreased nursing interventions 2-3 LPM as needed circulating hemoglobin
nanlalamig yung mga hemoglobin the client will be able and increases the
kamay niya” concentration to : effectiveness of blood
that is reaching the
Objective:  Demonstrate relief ischemic tissues
from chest pain
Capillary Refill=4 secs  Demonstrate a  This promotes optimal
2. Instructed to assume
RR=35 cpm decrease in the lung ventilation and
an high fowler’s
PR=126 bpm respiratory rate perfusion
position
Restlessness from 35-25 cpm
Nasal flaring  Conserves energy and
Cyanosis Long Term: lowers oxygen demand
RBC Count : 2.40x106/ul. After 3 days of of tissues
3. Provided a quiet and
Hemoglobin: 7.8g/dl nursing interventions
calm environment
Cold, clammy skin the client will be able
to:  Prevents venous stasis
 Demonstrate 4. Encouraged to perform and helps maintain
increased passive ROM exercises muscle tone of
perfusion as on the extremities extremities
manifested by: every 2-4 hours
o Capillary refill <3
secs
o RR= 16-20 cpm 5. Instructed to avoid  These activities may
o PR=80-100 bpm measures that may increase ICP and
o Acyanosis increase cardiac further reduce blood
workload such as flow
straining, coughing,
o RBC (4.6-6.2 neck or hip flexion and
x106/ul) and lying supine
hemoglobin (10-
18g/dl) count 6. Encouraged intake of  Iron is needed for the
within normal iron rich foods such as production of
parameters green leafy vegetables hemoglobin which in
turn supplies oxygen
to tissues

Dependent:

1. Administered iron  Provides supplemental

supplements as iron that can help
indicated improve hemoglobin
level

2. Administered Vitamin C
as indicated  Enhances absorption
of iron in the
gastrointestinal tract