Republic of the Philippines

Naval State University

College of Arts and Sciences
NURSING AND HEALTH SCIENCES DEPARTMENT
Naval, Biliran

NURSING CARE PLAN

NAME: Duba, Erlinda SEX: Female AGE: 70 years old WARD: Medical DATE: 08 13 17 SHIFT: 7:00am 3:00pm
DIAGNOSIS: CAP MR, BAIAE CHIEF COMPLAINTS: Fever, cough and difficulty of breathing PHYSICIAN: Dr. Sabornido
CUES NURSING DIAGNOSIS SCIENTIFIC ANALYSIS OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION
Subjective: Impaired gas exchange Community- General:
maglisod kog ginhawa related to alveolar acquired pneumonia (CAP) After two days of
as verbalized by the capillary membrane is a disease in which nursing intervention,
patient. changes such as individuals who have not the client will be able
pneumoconiosis as recently been hospitalized to demonstrate
Objective: evidenced by difficulty of develop an infection of improved ventilation
- Dry cough breathing, respiratory the lungs (pneumonia). and oxygenation of
- Pale appearance rate of 25 cycles per tissues within clients
- Restless minute, pulse rate of 98 CAP is a common illness normal limits.
- Difficulty beats per minute, and can affect people of all
Sleeping restless, cough and pale ages. CAP often causes Specific: Independent:
- Difficulty of in appearance. problems like difficulty in After eight hours of 1. Evaluate the clients vital 1. To assess respiratory
breathing breathing, fever, chest nursing interventions, capacity insufficiency
- Disturbed pains, and a cough. CAP the client will be able
thoughts and occurs because the areas to show: 2. Assist the client in a 2. Facilitate easier
feelings of the lung which absorb - clear breath semi-fowlers position breathing
- Facial grimace oxygen (alveoli) from the sounds
- Oxygen via atmosphere become filled - eliminate 3. Emphasize adequate rest 3. Promotes comfort
cannula with fluid and cannot work dyspnea
- V/S: effectively - respiratory
T 35.8 rate of <20

ACTUAL NURSING DIAGNOSIS

P 98 bpm Pneumonia also is the
R 25 cpm inflammation of the lung
BP 90/70mmhg parenchyma caused by
various microorganisms,
including bacteria,
mycobacteria, chlamydiae,
mycoplasma, fungi,
parasites and viruses. As
the lung parenchyma and
alveoli of the lungs are
inflamed it impairs gas
exchange due to the
alterations in the alveoli
which is the site for actual
gas exchange.
Source:
Black, Hawks and Keene,
Medical Surgical Nursing
6th Edition, Volume 1,
page 225.
cycles per 4.Encourage adequate oral 4. Helps liquefy secretions
minute fluid intake of 2000 ml per
- relaxation to day
condition
5.Have stand by oxygen 5.For emergency use
Dependent:
6. Administer mucolytics as 6. Decreases mucus
prescribed. viscosity
7. Administer antibiotics, as 7. Avoids further
ordered and monitor for multiplication of
side effects microorganisms.
8. Administer 8. Helps enhance passage
bronchodilator as of air to the airway.
recommended.
ACTUAL NURSING DIAGNOSIS
 Republic of the Philippines
Naval State University
College of Arts and Sciences
NURSING AND HEALTH SCIENCES DEPARTMENT
Naval, Biliran

NURSING CARE PLAN

NAME: Duba, Erlinda SEX: Female AGE: 70 years old WARD: Medical DATE: 08 13 17 SHIFT: 7:00am 3:00pm
DIAGNOSIS: CAP MR, BAIAE CHIEF COMPLAINTS: Fever, cough and difficulty of breathing PHYSICIAN: Dr. Sabornido
CUES NURSING DIAGNOSIS SCIENTIFIC ANALYSIS OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION
Subjective: Ineffective airway When an infectious Specific: Independent:
Naa koy ubo as clearance related to particles reach the sterile After eight hours of 1. Monitor respirations and 1. Indicative of respiratory
verbalized by the patient. excessive mucous lower respiratory tract, an nursing intervention breath sounds noting rate distress/ accumulation of
production. inflammatory response the client will be able and sounds. secretion.
Objective: develop thus producing to:
- Dry cough exudates that interferes - Maintain 2. Position head 2. To maintain open airway
- Pale appearance with diffusion of oxygen patent, appropriately forage/ in at rest or compromised
- Restless and carbon dioxide areas adequate condition. individuals.
- Difficulty of of the lungs are not airway.
breathing adequately ventilated 3. Suction secretion as 3. To clear airway when
- Facial grimace because of secretions and needed. excessive secretions that
- Oxygen via mucosal edema and the are blocking the airway.
cannula client experience
- V/S: difficulty of breathing. Collaborative:
T 35.8 4. Give expectorant/ 4. To mobilize secretions to
P 98 bpm bronchodilator (Salbutamol improve respiratory
R 25 cpm neb) function and gas exchange.
BP 90/70mmhg

ACTUAL NURSING DIAGNOSIS

Source: 5. Give O2 inhalation 5. To aid in breathing.
Medical Surgical 6. Give antibiotic as 6. To treat the underlying
Nursing, 11th edition by ordered. cause of illness.
Suddarth, page 550.
7. Infuse IVF. 7. To help loosen secretion.

ACTUAL NURSING DIAGNOSIS

 Republic of the Philippines
Naval State University
College of Arts and Sciences
NURSING AND HEALTH SCIENCES DEPARTMENT
Naval, Biliran

NURSING CARE PLAN

NAME: Duba, Erlinda SEX: Female AGE: 70 years old WARD: Medical DATE: 08 13 17 SHIFT: 7:00am 3:00pm
DIAGNOSIS: CAP MR, BAIAE CHIEF COMPLAINTS: Fever, cough and difficulty of breathing PHYSICIAN: Dr. Sabornido
CUES NURSING DIAGNOSIS SCIENTIFIC ANALYSIS OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION
Subjective: Acute pain related to Pneumonia is Specific: Independent:
masakit akong dughan localized inflammation inflammation of the After 8 hours of 1. Elevate head of the bed, 1. Lowers diaphragm,
kung muubo ko as and persistent cough terminal airways and nursing interventions, change position frequently. promoting chest expansion
verbalized by the patient. alveoli caused by acute the patient will display and expectoration of
infection by various patent airway with secretions.
Objective: agents. Pneumonia can be breath sounds clearing
- Dyspnea divided into three groups: and absence of 2. Assist patient with deep 2. Deep breathing
- Fatigue community acquired, dyspnea. breathing exercises. facilitates maximum
- Restless hospital or nursing home expansion of the lungs and
- Dry cough acquired (nosocomial), smaller airways.
- Pale appearance and pneumonia in an
- V/S taken as immunocompromised 3. Demonstrate or help 3. Coughing is a natural
follows: person. Causes include patient learn to perform self-cleaning mechanism.
T- 35.8 bacteria (Streptococcus, activity like splinting chest Splinting reduces chest
P- 98 Staphylococcus, and effective coughing discomfort, and an upright
R- 25 Haemophilus influenzae, while in upright position. position favors deeper,
BP- 90/70mmHg Klebsiella, Legionella). more forceful cough effort.
Community Acquired
Pneumonia (CAD) is a 4. Force fluids to at least 4. Fluids especially warm
disease in which 2000 ml per day and offer liquids aid in mobilization
individuals who have not

ACTUAL NURSING DIAGNOSIS

recently been hospitalized warm, rather than cold and expectoration of
develop an infection of fluids secretions.
the lungs. It is an acute
inflammatory condition
thats result from Collaborative:
aspiration of 5. Administer medications 5. Aids in reduction of
oropharyngeal secretions as prescribe: mucolytics or bronchospasm and
or stomach contents in expectorants. mobilization of secretions.
the lungs.
6. Provide supplemental 6. Fluids are required to
Source: fluids. replace losses and aid in
Medical Surgical mobilization of secretions.
Nursing, 11th edition by
Suddarth, page 600.

ACTUAL NURSING DIAGNOSIS