B.1 NURSING CARE PLAN

Patient: Ibonalo, Simeon Sabal Hospital no. IP

Age: 80years old Room no. FW-9

Impression/Diagnosis: Pneumonia Physician: Guangko, Amelita S.

Nurse’s Name and Signature: Go, Bevelyn B. N

CLINICAL PORTRAIT PERTINENT DATAAssessment:

Received patient lying on bed, awake, conscious, and afebrile,

with ongoing IVF of PNSS 1L @ 10gtts/min infusing well at his

left arm.

Significant Findings:

Patient was weak, restlessness and expressed his feelings by

holding the person behind him. Noted teary eyes. Rales and

rhonchi heard upon auscultation.

Vital Signs during First Contact:

T- 37.2 degree Celsius

P-83 beats per minute

R-VR

History of present Illness:

A case of Ibonalo, Simeon Sabal , 80 years old, malem Filipino,

Roman Catholic from J. Labra St. Guadalupe Cebu City was

admitted at Visayas Community Medical Center.

5 days prior to admission patient was noted to had hiccup. Patient

was weak. Decrease sensorium and increase dyspnea episode and

was brought by ERUF to VCMC.

Chief Complaint:

Dyspnea

Health History relevant to Present Condition:

Patient was experienced difficulty in breathing sinch he was 67

years old because of that he was hospitalized 3 times. He was a

tobacco user.

Vital signs taken during admission:

BP-130/80 mmHg

NURSING DIAGNOSIS:

1. impaired breathing pattern related to broncocostriction.

2. effective airway clearance related to mucus production

3. risk for injured skin integrity related to prolonged

immobilization.

T- 37.6 degree Celsius

P-83 beats per minute

R-28 cycles per minute

BP-140/90 mmHg

URINALYSIS REPORT

Test Results Normal Basis

Appearance

Color

Odor

pH

Protein

Specific Gravity

Glucose

Casts

Cloudy

Dark yellow

Aromatic

6.0

(+)

1.02d

(-)

None

Clear

Amber

Aromatic

4.6-8.0

(-)

1.005-1.030

(-)

None

HEMATOLOGY SECTION

TEST NAME RESULT UNIT REFERENCE

RANGE

WBC 3.18 L K/uL 4.1-10.9

Segmenters

Lympho

Mono

Eosinophil

Basophils

RBC

Hemoglobin

hematocrit

MCV

MCH

MCHC

RDW-SD

RDW-CV

Platelet

MP

78.40

16.00

4.40

0.30

0.90

4012

11.80L

35.60L

86.40

28.60

33.10

50.90

16.5H

256.00

10.50

%

%

%

%

%

M/uL

g/dl

%

fL

pg

g/dl

fL

%

K/uL

fL

47.0-80.0

130.0-40.0

2.0-11.0

0-5.0

0-2.0

4.5-5.9

13.5-17.5

41.0-53.0

80.0-100.0

23.0-34.0

31.0-36.0

37.0-54.0

11.6-11-4.8

140.0-440.0

0-99.0

CUES/EVIDENCES NURSING DIAGNOSIS

SCIENTIFIC BASIS

GOALS AND OUTCOME CRITERIA

NURSING ACTION AND NURSING ORDERS

RATIONALE EVALUATION

Subjective cues:

“maglisod man ako

papa og ginhawa

day tungod sa iyang

ubo” as verbalized

by the S.O of the

patient.

Objective cues:

Received patient

lying on bed, awake,

afebrile with

ongoing IVF of

PNSS 1L @

10gtts/min.

-Dyspnea

-Adventitious breath

sounds rales and

Ineffective

airway

clearance

related to

presence of

mucus

production.

Inability to

clear

secretions

or

obstruction

from the

respiratory

tract to

maintain a

clear

airway.

(Doenges;

2006;66)

After 8 hrs. of

effective

nursing

intervention

the patient

will be able to

mobilize

airway is free

of secretions.

The Patient

will be able to

1.to

maintain

airway

patency

Independent:

-asses rate/depth of

respiration and chest

movement and

monitor for

respiratory failure

-Suction

-to reduce discomfort of

moving chest wall or

fluid in the lung.

(doenges,6th edition;67)

-to clear airway when

secretions are blocking

Goal not met:

After 8 hours

of nursing

intervention

patients is not

able to

expectorate

secretions and

still has

difficulty in

breathing.

rhonchi

-Restlessness

-Presence of sputum

-wide-eyed

-cyanosis

2. to

mobili

zed

secreti

ons

naso/trachel/oral prn

-Elevate head of the

bed/ change position

every two hours

DEPENDENT

-Administer/

monitor medication

regimen and note

client response.

-regulate the

intravenous fluid as

airway (doenges,6th

edition;67.)

-To decrease pressure in

the diaphragm/

promoting chest

expansion.

(doenges,6th edition;67)

-to determine

effectiveness of

theraphy/ presence of

side effects(doenges,6th

edition;67)

-to promote fast

recovery(doenges,6th

edition;67)

-to promote

relaxation(doenges,6th

3.To assess

changes and

note

complication.

ordered

-give expertorants/

bronchodilatores

COLLABORATIVE

-assist with medical

procedures

-administer

humidified oxygen

-suggest support

group for significant

others.

edition;67)

-to save time & energy.

(doenges,6th edition;67)

-humidity reduces

viscosity of

secretions(doenges,6th

edition;67)

-to assst woth understanding of way to deal with clients. (doenges,6th edition;67

Subjective cues:

“ naglisod akong

papa og ginhawa”

as verbalized by the

S.O of the patient.

Objective cues:

Received patient

lying on bed, awake,

afebrile with

ongoing IVF of

PNSS 1L @

10gtts/min.

-Dyspnea

-hypoxia

-tachycardia

-restlessness

-changes in

mentation

Impaired

breathing

pattern

related to

bronco-

constriction

After 8 hrs. of

effective

nursing

intervention

the patient

will be able

breathe

effectively.

The Patient

will be able to

-Gain

knowledge

about her

condition

Independent:

1. teach patient that

causes difficulty in

breathing

- to gain knowledge

about the causes of

difficulty in

breathing(doenges,6th

edition;104)

Goal not met:

Patient had

still difficulty

in breathing

- Perform

certain

position that

would

promote

effective

breathing

-.administer

supplemental

oxygen by cannula

or mask, as

indicated:

-Review Laboratory

results as indicated

- elevate head of

bed, in upright or

semi-fowler’s

position.

- Encourage client

participation/

responsibility for

deep breathing

- Enhances oxygen

delivery to the lung for

circulatory uptake,

especially in presence of

reduced/altered

ventilation(doenges,6th

edition;104)

- Monitor effectiveness

of respiratory therapy.

(doenges,6th edition;104)

- Stimulates respiratory

function/lung

expansion.doenges,6th

edition;104)

- aids in reexpansion/

maintaining patency of

small airway(doenges,6th

edition;104)

-to have life

style Changes

exercises, use of

adjuncts, and

coughing, as

indicated

-refer to a physician

if dyspneic worsens.

- encourage patient

to minimize

smoking

- instruct patient to

have a follow-up as

indicted

- Refer to social

services for further

counseling

- provides continuity of

care. (doenges,6th

edition;104)

- smoking would

aggreviate difficulty in

breathing(doenges,6th

edition;104

- aids in monitoring and

effects of medications.

(doenges,6th edition;188)

- promote patient’s

cooperation.(doenges,6th

edition;188)

B.2DISCHARGE PLAN

Patient: Ibonalo, Simeon Sabal Hospital no. IP

Age: 80years old Room no. FW-9

Impression/Diagnosis: Pneumonia Physician: Guangko, Amelita S.

Nurse’s Name and Signature: Go, Bevelyn B. UCCN

PATIENT’S OUTCOME CRITERIA NURSING ORDERAs soon as the patient is admitted and

discharged from the medical ward of Visayas

Community Medical Center, the patient will be

able to:

Assessment:

> Assess for the patient’s vital signs.

>Assess for unusual findings.

Planning:

> Plan for a scheduled visits/ consultations.

> monitor vital signs taking every four hours,

notify deviations from baseline that are

indicative of infection:

-increase in temperature

-increase in respiratory rate

> monitor for signs and symptoms.

-dyspnea

-fever

-cyanosis

>Encourage the patient to outpatient visits for

consultations:

> Plan for activities necessary for easy coping

to the disease.

Implementation:

M> Comply with take home medications as

prescribed by the doctor.

E>Provide a conducive environment necessary

for the patient’s condition.

T> Maintain a healthy lifestyle and monitor

health status

H> Be able to practice health promotion and

illness prevention.

O> Have a clinical visit at least once a week

> Encourage patient to ambulate early in the

morning.

> Administer medications as indicated.

>Explain the importance of the effect of

environment towards the recovery of the

patient.

> Monitor intake and output balance.

> Ascertain patient’s knowledge about

postpartum care.

> Encourage the patient to follow a healthy

lifestyle. Make a calendar planner for visits

during her free time.

D> Follow dietary guidelines to enhance

nutritional requirements with special

considerations on financial capacity.

S> Provide support and comfort.

Evaluation:

Be aware of the condition positively

and learn to cope with her new change

in lifestyle.

> Encourage the patient to follow a healthy

eating pattern.

> Explore ways in which significant others can

be supportive and in ways they could help.

> Encourage the patient to comply with the

interventions given and continue with it at

home and be able to follow-up evaluation of

heath status.