NURSING CARE PLAN
ASSESSMENT
Subjective:
“Hindi ako
komportable,
medyo
nahihirapan
ako dahil
masakit paa
ko”, as
verbalized by
the patient.

7/10 pain
scale
Objective:
- Facial
grimace
- Positioning
to ease pain
from her left
leg.
- Limited
movement
- HR: 110
bpm
NURSING
DIAGNOSIS
Acute Pain
as
evidenced
by reports
of pain,
facial
grimace and
position to
ease
comfort.
SCIENTIFIC
BACKGROUND
Inflammation
Edematous leg
Warmth and redness
Decreased function of
right leg
Acute pain
Doenges, M. E., Moorhouse,
F., & Murr, A. C. (2019).
NURSES'S POCKET GUIDE
Diagnoses, Prioritized
Interventions, and Rationales
(15th ed.). F.A. DAVIS
COMPANY.
NURSING
OBJECTIVES
Short-term
Goal:
July 31, 2023
7-4 shift
After rendering 6
hours of nursing
intervention, the
patient’s will be
alleviated with:
NURSING INTERVENTIONS
Independent:
1. Consider reports of pain,
noting
location
and
intensity (scale of 0–10).
2. Monitor the duration,
- Pain scale of not the intensity, of
2/10
morning stiffness.
No
facial
grimace
3. Suggest patient assume
-HR: 95 bpm
a position of comfort while
in bed or sitting in a chair.
Promote
bedrest
as
indicated.
4. Encourage
frequent
changes of position. Assist
the patient to move in bed,
RATIONALE
EVALUATION
Short-term
Goal:
1. Note
precipitating July 31, 2023
factors and nonverbal 7-4 shift
pain cues.
Favorable in determining After
pain management needs rendering
6
and effectiveness of the hours
of
program.
nursing
intervention,
2. Duration
more the patient’s
accurately reflects the pain
was
disease’s severity.
alleviated
with:
3. In severe disease or
acute exacerbation, total - Pain scale of
bedrest may be necessary 3/10
(until
objective and - No facial
subjective improvements grimace
are noted) to limit pain or -HR: 97 bpm
injury to the joint.
“Goal Met”
4. Prevents
general
fatigue
and
joint
stiffness.
Stabilizes
supporting affected joints joints, decreasing joint
above and below, and movement
and
avoiding jerky movements. associated pain.
5. Encourage to do proper 5. It is to help in pain
deep breathing technique.
management
and
provides relaxation for
the patient.
Dependent:
Administer medications as
ordered:
6. Tramadol 50mg, IV, q8
7. Eperisone 1 tab, tid, pc
6. To relieve pain.
7. To relieve pain.
8. Prednisone 20mg, 1 tab,
bid pc x5 days
8. to relieve pain.
ASSESSMENT
Objective:
Altered
oxygen
supply: O2
saturation of
93%
RR: 22 bpm
-With
abnormal
breath
sounds,
rhonchi and
crackles
- HR: 110
bpm
-Use of
accessory
muscle.
NURSING
DIAGNOSIS
Risk for
Impaired
Gas
Exchange
SCIENTIFIC
BACKGROUND
NURSING
OBJECTIVES
Effects of endotoxins on Short-term
respiratory center
Goal:
July 31, 2023
Hypoventilation
7-4 shift
Risk for impaired gas
exchange
Doenges, M. E., Moorhouse,
F., & Murr, A. C. (2019).
NURSES'S POCKET GUIDE
Diagnoses, Prioritized
Interventions, and Rationales
(15th ed.). F.A. DAVIS
COMPANY.
NURSING INTERVENTIONS
Independent:
RATIONALE
EVALUATION
Short-term
Goal:
1. Rapid,
shallow July 31, 2023
respiration
occurs 7-4 shift
because of hypoxemia,
stress, and circulating After
endotoxins.
rendering
6
Hypoventilation
and hours
of
dyspnea
reflect nursing
ineffective compensatory intervention,
mechanisms and are the patient’s
indications
that experienced
ventilatory support is no tachycardia
needed.
or cyanosis as
evidenced by:
1. Monitor respiratory rate
and depth. Note the use of
accessory muscles or work
After rendering 6 of breathing.
hours of nursing
intervention, the Rapid, shallow respiration
patient’s
will occurs
because
of
experience
no hypoxemia, stress, and
tachycardia
or circulating
endotoxins.
cyanosis
as Hypoventilation
and
evidenced by:
dyspnea reflect ineffective
compensatory mechanisms
HR: 95 bpm
and are indications that
O2Sat: 95%
ventilatory
support
is
RR: 20 bpm
needed.
HR: 97 bpm
No
signs
of
O2Sat: 95%
abnormal breath 2. Note the presence of 2. Circumoral cyanosis RR: 20 bpm
sounds.
circumoral cyanosis.
indicates
inadequate
central oxygenation and
“Goal
hypoxemia.
Partially
Met”
3.Note
cough
and
3. Note cough and purulent purulent
sputum
sputum production.
production.
4. Monitor ABGs
pulse oximetry.
and 4.Hypoxemia is related
to decreased ventilation
and pulmonary changes
(i.e.
atelectasis,
interstitial edema, and
pulmonary shunting) and
increased
oxygen
demands caused by fever
or infection.
5. Reposition the client
frequently.
Encourage
coughing
and
deepbreathing exercises.
5. A good pulmonary
toilet is important for
minimizing
ventilation/perfusion
imbalance
and
for
mobilizing
and
facilitating the removal
of
secretions
to
maximize gas exchange.
6. Maintain the client’s
airway. Place the client in
a position of comfort with
the head of the bed
elevated 30 to 45°.
6.Elevating the head of
the bed enhances lung
expansion and reduces
respiratory effort.
Dependent:
7. Provide
supplemental
oxygen via the appropriate
route: nasal cannula, 4
lpm.
7.Supplemental oxygen
is important for the
correction of hypoxemia
with failing respiratory
effort or progressing
acidosis.
ASSESSMENT
Subjective:
“Inaatake ako ng
asthma kapag
maalikabok, o
kaya may malakas
na cologne at mga
usok,” as
verbalized by the
patient.
Objective:
Altered
oxygen
supply:
O2
saturation of 93%
- HR: 110 bpm
- RR: 22 bpm
- With abnormal
breath
sounds,
rhonchi
and
crackles
- Use of accessory
muscle.
-Nasal flaring
NURSING
DIAGNOSIS
Ineffective
Breathing
Pattern
related to
swelling
and spasm
of
the
bronchial
tubes
in
response to
inhaled
irritants,
allergies as
evidenced
by cough,
nasal
flaring,
tachympnea
, use of
accessory
muscles.
SCIENTIFIC
BACKGROUND
Inhaled irritants
(cologne, dust, smoke)
Swelling and spasm of
bronchial tubes
Ineffective breathing
pattern
Doenges, M. E., Moorhouse,
F., & Murr, A. C. (2019).
NURSES'S POCKET GUIDE
Diagnoses, Prioritized
Interventions, and Rationales
(15th ed.). F.A. DAVIS
COMPANY.
NURSING
OBJECTIVES
NURSING INTERVENTIONS
Short-term
Goal:
July 31, 2023
7-4 shift
Independent:
1. Assess the client’s vital
signs as needed.
After rendering 6
hours of nursing
intervention, the
patient’s
will
maintain
an
optimal breathing
pattern,
as
evidenced by:
HR: 95 bpm
O2Sat: 95%
RR: 20 bpm
No
signs
of
abnormal breath
sounds.
No
use
accessory
muscles.
2. Assess for signs of
dyspnea (flaring of nostrils,
chest retractions, and use of
accessory muscle).
of
No
observed
nasal flaring.
3. Monitor
saturation.
oxygen
RATIONALE
EVALUATION
Short-term
Goal:
1.Increased respirations, July 31, 2023
tachycardia,
7-4 shift
and hypotension may
result from the effects of After
hypoxia. Hypoxia results rendering
6
from
vasoconstriction hours
of
which is an adaptive nursing
response
to intervention,
ventilation/perfusion
the patient’s
mismatch.
will maintain
an
optimal
breathing
2. Dyspnea may indicate pattern,
as
respiratory
distress. evidenced by:
Once the movement of
air into and out of the HR: 97 bpm
lungs
becomes O2Sat: 95%
challenging,
the RR: 20 bpm
breathing
pattern
changes.
No use of
accessory
3.In a mild episode, muscles.
oxygen saturation with
room air is greater than No observed
95%; in a moderately nasal flaring.
severe episode, it can be
91 to 95%; and,d in
severe episodes it can be
less than 91% (Morris &
Mosenifar, 2022).
4. Maintain the head of the
bed elevated and position
the client depending on
respiratory effort.
4.Head elevation and left
lateral Sims position to
prevent aspiration of
secretions or vomitus,
enhance ventilation to
lower lobes, and relieve
pressure
on
the
diaphragm.
5. Encourage the client to 5.In people diagnosed
use breathing exercises.
with
asthma,
the
presence
of
dysfunctional breathing
independently
of
hyperventilation
can
contribute to dyspnea.
6. Educate about
environmental control and
allergen avoidance.
6.Environmental
exposures and irritants
can play a strong role in
symptom exacerbations.
7. Avoid secondhand
smokers.
7.Education to
tobacco smoke
firsthand
avoid
(both
and
“Goal
Partially
Met”
secondhand exposure) is
important for clients
diagnosed with asthma.
Dependent:
8. Administer medication as 8.Adding
ipratropium
ordered:
bromide to salbutamol in
the treatment of acute
- Salbutamol + ipatropium asthma produces a small
1 neb now, then PRN if improvement in lung
DOB
function, and reduces the
risk of the need for
additional
treatment,
subsequent
asthma
exacerbations,
ASSESSMENT
Subjective:
“Hindi
ako
komportable,
medyo
nahihirapan
ako
dahil
masakit
paa
ko”,
as
verbalized by
the patient.
Objective:
- HR: 110 bpm
- RR: 22 bpm
- Weakness
- Limited ROM
- Discomfort
NURSING
DIAGNOSIS
Impaired
Physical
Mobility as
evidenced
by limited
ROM.
SCIENTIFIC BACKGROUND
Inflammation of joint
Pain
Limiting movement
Decreased muscle
strength
Impaired physical
mobility
Doenges, M. E., Moorhouse,
F., & Murr, A. C. (2019).
NURSES'S POCKET GUIDE
Diagnoses, Prioritized
Interventions, and Rationales
(15th ed.). F.A. DAVIS
COMPANY.
NURSING
OBJECTIVES
Short-term
Goal:
July 31, 2023
7-4 shift
After rendering 6
hours of nursing
intervention, the
patient’s
will
maintain position
of function with
limitation
contractures, as
evidenced by:
HR: 95 bpm
O2Sat: 95%
RR: 20 bpm
- Increased ROM
- No signs of
discomfort (facial
grimace)
NURSING INTERVENTIONS
Independent:
1. Assess and continuously
monitor the degree of joint
inflammation and pain.
2. Assist with active and
passive ROM and resistive
exercises and isometrics
when able.
3. Discuss and provide
safety needs such as raised
chairs and toilet seats, use
of handrails in the tub,
shower, and toilet, proper
use of mobility aids, and
wheelchair safety.
RATIONALE
EVALUATION
Short-term
Goal:
1. The level of activity July 31, 2023
and exercise depends on 7-4 shift
the progression and
resolution
of
the After
inflammatory process.
rendering 6
hours
of
2.Maintains
and nursing
improves joint function, intervention,
muscle strength, and the
patient
general stamina. Note: maintained
Inadequate
exercise position
of
leads to joint stiffening, function with
whereas
excessive limitation
activity can damage contractures,
joints.
as evidenced
by:
3.Helps
prevent
accidental injuries and HR: 97 bpm
falls.
O2Sat: 95%
RR: 20 bpm
Slightly
increased
ROM
- No signs of
discomfort
4. Position with pillows.
Dependent:
5. Administer
as ordered:
(facial
4.Promotes joint stability grimace)
(reducing risk of injury)
and maintains proper
“Goal
joint position and body
Partially
alignment, minimizing
Met”
contractures.
medication
- Tramadol 50mg, IV, q8
- To relieve pain.
- Eperisone 1 tab, tid, pc
- To relieve pain.