9NCP

8/8/2019 9NCP

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NURSING CARE PLAN

ASSESSMENTNURSING

DIAGNOSISOUTCOME

IDENTIFICATIONINTERVENTION RATIONALE

NURSINGTHEORIES

EVALUATION

Subjective:

- Budlayan ko

mag-ginhawa, as

verbalized.

Objective:

- abnormal lung

sounds (rales,

wheezing)

- chest X-rays

indicate

pulmonary

congestion

- tachypnea:

RR 24 bpm

- 3 pillow

orthopnea

Ineffective

Airway

Clearance

related to

broncho-

constriction

To promote

effective airway

clearance as

evidenced by

eupnea & clear

lung sounds within

the shift.

Independent Virginia

Hendersons 14

Components of

Nursing Care

Faye Abdellahs 21

Nursing Problems

Imogene Kings

Nurse-Patient

Interactions

GOAL MET:

Patient replied,

Indi naman ah

when asked if

its still difficult

for him to

breathe.

No abnormal

lung sounds

heard upon

auscultation.

Respirations

are regular and

the RR is 20

bpm, within the

normal range.

Maintain adequate

hydration.

Fluids lost by diaphoresis,

fever, and tachypnea need

to be replaced to prevent

dehydration.

Place patient on High-

Fowlers position and

encourage bed rest.

Elevation of the thorax

facilitates lung expansion,

diaphragm contraction and

bed rest promotes bronchial

relaxation.

Encourage avoidance of

air pollution exposure and

cessation of smoking.

Bronchial irritants further

aggravate the chronic

inflammatory process in the

lungs.

Dependent

Administer Iterax,

Montiget, and Prednisone

Anti-inflammatory drugs

reduce inflammation.

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as ordered.

Administer Ventolin and

Seretide as ordered.

Bronchodilators treat

bronchoconstriction and

promote airway clearance.

Administer Levox and

Diflucan as ordered.

Antibiotics and antifungals

treat the infection and

eliminate the cause of

inflammation.

ASSESSMENTNURSING

DIAGNOSISOUTCOME


NURSINGTHEORIES

EVALUATION

Objective:

- shallow and

labored breathing

Impaired

Gas

Exchange

To promote

optimal gas

exchange as

Independent Myra Levines

Conservation of

Energy Theory

GOAL MET:

Respirations

are regular and

Promote bed rest and

decrease activity.

Activities increase oxygen

consumption.

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- tachypnea (RR

of 24 bpm)

- restlessness

- Laboratory

results show:

Hgb 123 g/dL

Hct 0.37 vol.fr

RBC 3.96 x

1012/L

O2 Saturation

92.5%

(all indicating poor

oxygenation)

related to

ventilation-

perfusion

inequality

evidenced by

eupnea and alert

responsive mental

status within the

shift.

Virginia

Hendersons 14

Components of

Nursing Care

Faye Abdellahs 21

Nursing Problems

Florence

Nightingales

Environmental

Theory

the RR is 20

bpm, within the

normal range.

Patient is alert

and

conversational.

O2 saturation

98.9%

Ensure adequate

ventilation. If possible, turn

off air conditioning unit

and open windows.

Air conditioning units give

off air with lower oxygen

concentration than air from

the environment.

Dependent





promote airway clearance.

Collaborative

Administer supplemental

oxygen via nasal cannula

at 2 Lpm.

O2 therapy facilitates the

delivery of adequate O2 to

the body cells.

ASSESSMENTNURSING

DIAGNOSISOUTCOME


NURSINGTHEORIES

EVALUATION

Objective:

- use of the

accessory

muscles of

Ineffective

Breathing

Pattern

related to

To establish and

maintain an

effective breathing

pattern as

Independent Betty Neumans

Theory of Systems

Stability

GOAL MET:

Patient exhibits

ease in

respiration and

Teach patient

diaphragmatic and

pursed-lip breathing.

Helps patient prolong

expiration time and

decreases air trapping.

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respiration (leans

forward and

elevates

shoulders when

breathing)

- shallow and

labored breathing

- tachypnea (RR

of 24 bpm)

broncho-

constriction

evidenced by

eupnea within the

shift.

Lydia Halls Core

and Cure Theory

Faye Abdellahs 21

Nursing Problems

Myra Levines

Conservation of

Energy Theory

performs

diaphragmatic

breathing when

feeling short of

breath.

Use of

accessory

muscles of

respiration

reduced.

Encourage rest and

moderation in physical

activity.

Strenuous activity tires the

respiratory muscles and

causes ineffective

respiration.

Dependent





promote airway clearance,

thus facilitating effective

respiration.

ASSESSMENTNURSING

DIAGNOSISOUTCOME


NURSINGTHEORIES

EVALUATION

Objective:

- grooming is

poor

- nai ls are uncut

dirty

Self-Care

Deficit

related to

fatigue

secondary

To promote self-

care and perform

self-care activities

independently

within the shift.

Independent Dorothea Orems

Self-Care Deficit

Theory

Helen Erickson,

GOAL NOT

MET:

Patient was

unable to

perform self-

Teach patient to

coordinate diaphragmatic

breathing with activity.

This will allow the patient to

be more active and to avoid

excessive fatigue or

dyspnea during activity.

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- general

weakness and

fatigue

- inability to

exert force on

muscles

to increased

work of

breathing

and

insufficient

ventilation

and

oxygenation

Evelyn Tomlin, and

Mary Ann Swains

Modeling and Role

Modeling Theory

Myra Levines

Conservation of

Energy Theory

care activities

and continued

to be

dependent on

family members

and nurse.

Encourage patient to

begin to bathe self, dress

self, walk and drink fluids.

Discuss energy

conservation methods.

As condition resolves,

patient will be able to do

more but needs to be

encouraged to avoid

increasing dependence.

ASSESSMENTNURSING

DIAGNOSISOUTCOME


NURSINGTHEORIES

EVALUATION

Subjective:

- Indi ko kasarang

pa magbangon, as

verbalized.

Objective:

- general

Activity

Intolerance

related to

fatigue,

hypoxemia

To improve

tolerance in

physical activity

as evidenced by

participation in

physical exercises

within period of

Independent Sister Callista

Roys Adaptation

Theory

Hildegarde

Peplaus

Therapeutic

GOAL

PARTIALLY

MET:

Patient was

able to tolerate

passive ROM

exercises but

Perform Passive ROM

exercise every day.

Conditions muscles to

activity and prevents

atrophy.

Provide encouragementand positive feedback on

patients efforts.

Therapeutic onpsychological aspect of the

patient and promotes

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weakness and

fatigue

- inability to

exert force on

muscles

- discomfort

during

performance

of PROM

exercises

hospitalization. . compliance to the plan of

care.

Interaction Process

Martha Rodgers

Theory of

Homeodynamics

has not

progressed to

Active ROM

exercises yet. Teach family members

proper rehabilitative

methods to ensure that

muscles regain maximum

strength.

Family members will

continue the plan of care

after discharge.

ASSESSMENTNURSING

DIAGNOSISOUTCOME


NURSINGTHEORIES

EVALUATION

Risk Factors:

- Patient is

presently

unemployed

due to the

medical

condition

- Pat ient re lies

on the monthly

Risk for

Ineffective

Coping

related to

the inability

to work

To promote and

maintain an

optimal level of

functioning within

period of

hospitalization.

Independent Sister Callista

Roys Adaptation

Theory

Betty Neumans

Health Systems

Stability Theory

Imogine Kings

GOAL

PARTIALLY

MET:

Patient has set

goals and is

determined to

cope with the

illness.

However,

Help the patient develop

realistic goals.

Promotes a sense of hope

and accomplishment rather

tan defeat and

hopelessness.

Encourage activity to level

of symptom tolerance.

Activity reduces tension

and decreases degree ofdyspnea as patient

becomes conditioned.

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salary of his

two eldest

children

- Patient

verbalized

Kagasto na

gid subong

sang

pangabuhi, na

ospital pa ta.

Theory of Nurse-

Patient Interactions

Joyce Travelbees

Finding Meaning in

Illness Theory

optimal level of

functioning was

not achieved

yet.

Teach relaxation

techniques.

Relaxation reduces stress,

anxiety and dyspnea, and

helps patient cope with

disability.

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