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Nursing Care Plan

Assessment Diagnosis Planning Intervention Rationale EvaluationSubjective:Objective:

- RR 30- Use of

accessorymuscles(nasalflaring)

- (+)crackleson bothlungsuponauscultation.

- Withnasalcannulaat 2l/min

- Po2 92%- Thick

greenishsecretionswith foulodor.

Ineffectiveairwayclearancerelated to

increaseproduction ofsecretions andincreasedviscosity.

After a series ofnursinginterventionspatients

Short term goal of8hrs- Airway

secretionswill belessenedasevidencedby notusingaccessorymusclessuch asnasalflaring.

Long term goal of1week.

- Airwaysecretionswill beabsent asevidencedby normalRRrangingfrom 16-20, andabsence ofcracklesuponauscultation.

Independent- Further

establishrapport.

-Position patientsemi fowlersposition.

- Encourage fluidintake unlesscontraindicated

- Perform chesttapping

- Suctionpatientssecretions

- Encouragepatient toperform deepbreathingexercise.

- Health teaching(Proper deepbreathingexercise,diseaseprocess,prevention ofcomplicationsand control ofthe disease.)

Dependent- 0xygen

administration.

- Administerprescribedmedications.

Collaborative- Coordinate with

radiologist forchest x-ray

- Coordinate withdietician forproper diet.

- Collaboratewith laboratoryfor laboratoryresults.

Independent-To gain trust ofpatient.

-For better lungexpansion.

-To liquefysecretions.

-To loosensecretions.-To lessensecretions.

-To facilitate clearairway. Brunner

-For management ofdisease.

Dependent-to improve clinicalsigns andsymptoms, patientcomfort andadequateoxygenation.Brunner-to promote betterwellness.

After a series ofnursing interventionpatients..short term goal of

8hours.- Airway

secretionswerelessen asevidencedby notusing ofaccessorymuscles.(Goal met)

Long term goal 1week.

- airwaysecretionswasabsent asevidencedby loweredRR from33 to 25,

Andabsence ofcrackles.

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Assessment Diagnosis

Planning Intervention Rationale Evaluation

Subjective:Objective:

- Pittingedema of3 cm uponpalpation.

- v/s:BP:130/90PR: 64RR: 30O2: 92%

- Poor skinturgor

- Intake:580Output:400

Excess fluidvolume r/twater/sodium

retention AEBskinindentation of3 cm uponpalpitation

After series ofnursing interventionpatient

Short term goal of8hrs

- Excess fluidwill beremoved

AEBincreasedurineoutput.

Long term goal of1week.

- Patientsfluid will benormalized

AEBabsencesof pittingedema andnormal I &O

Independent- Further establish

rapport.

- Record I & O.- Weigh daily

save the eachday

- Assess difficultareas for edema(face,foot,legs,hands,arms)

- Turning ofpatient every 2

hours.- Health teaching

(diseaseprocessprevention ofcomplication andcontrol.)

Dependent- Prescribe meds

by physician- Restrict or

administer fluid

as indicatedCollaborative

- Collaborate withdietician forproper diets.

- Collaborate withlaboratory forlaboratoryresults.

Independent-to gain trust ofpatient.

-to record for anydehydration.-to check if weightloss or weight gain.

- to know extent ofthe edema

-to prevent bedsore and proper

circulation.-for management ofdisease.

Dependent- to promote betterwellness- To maintain

equilibrium on

patients bodyfluids.

After a series ofnursing interventionpatients..

Short term goal of8hrs.

- Excessfluid asremovedby intakeof 500 andincreasedurineoutput of720.(Partially

Met.)Long term goal

- Patientfluid wasnormalizedbyabsence opittingedemaafter I & Oandweighing.

(GoalMet.)

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Assessment Diagnosis Planning Intervention Rationale EvaluationSubjective:Objective:

- (+) bloodin stool

AEBfecalysis

- Hgb115g/L

- Pale skin- Black

tarry stool- Weak in

appearance

- Bloodtype O+

Impairedgastrointestinaltissueperfusion r/tExcess gastricacidmanifested by

black tarrystool.

After a series ofnursing interventionpatientShort term goal of8hrs.

- Patientsbleeding will

preventedasevidencedby absenceof blacktarry stool

Long term goal of 1week

- Goodgastrointestinalperfusions.

Asevidencedby (-) bloodin stool.

Independent- Further establish

rapport- Monitor I & O

- Monitor v/s andpossible GIbleeding

- Health Teaching(Diseaseprocess,Prevention ofcomplication andcontrol.)

Dependent- Monitor meds

prescribed byphysicianCollaborative

- Collaborativewith lab withlaboratory result.

- Collaborate withdietician forproper diet.

Independent-to gain trustof patient.-to monitor foranydehydration.- To monitor

any change inhealth statusof thepatients.-formanagementof disease.

Dependent- to promote

betterwellness

After a series ofnursing interventionpatientShort term goal of8hrs.

- Patientbleeding was

lessen asevidenced bystool colorconsistency.(Goal PartiallyMet)

Long term goal of 1week

- Patientgastrointestinal perfusionwas good as

evidenced by.(-) blood instool.

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