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Republic of the Philippines

BICOL UNIVERSITY TABACO CAMPUS


NURSING DEPARTMENT
Tabaco City

STUDENT NURSE: LEVEL GROUP NO.: Level 2 Group 5


DATE OF CLINICAL PRACTICUM:

NURSING CARE PLAN

Date/ ASSESSTMENT NURSING PLANNING INTERVENTION EVALUATION


Time DIAGNOSIS
Dependent/
Goal Desired/ Expected Independent/ Rationale
Outcome (s) Collaborative

Subjective: After the nursing After the nursing Independent:


11-13-21 Ineffective airway interventions: interventions:  Monitor vital  To determine After the nursing
The mother of clearance due to The patient can The patient restores signs and appropriate interventions the
the patient coronavirus express sign of breathing pattern oxygen interventions. goal and expected
reported that her infection relief and back to normal and saturation outcome has met.
baby is suffering evidenced by improvement. demonstrates every 2 hours. The patient’s
in abdominal dyspnea and improved airway condition was
discomfort and coughing episodes Good health patency.  Assess improved. The
 To detect
difficulty in condition/complain Good response to respiratory patient’s safety
wheezes which
breathing. ts are being solved. the administered function by and comfort were
indicate
medications. noting the maintained.
accumulation
Objective: The patient will be sound, rate,
of secretions
able to maintain Rests and conserves rhythm, and
and inability to
(+) dyspnea airway patency and energy by limiting depth of
clear airways
Vital Signs: improved airway activities and breaths.
that may result
Temp: 36.4° clearance. remaining in bed to increased
Rr: 32cpm Negative Results in while symptomatic work of
PR: 112 bpm SARS COV and then slowly breathing.
O2 sat: 98% Antigen test. increasing activities.
 Place the
BU-F-TC-41
Effectivity Date: Nov. 29,2013
Revision NO.:0
W: 7.6 kg Maintains adequate patient in semi  To aid in lung
H: 69 cm hydration. or high- expansion and
Complies with Fowler’s reduce
management position. respiratory
strategies. effort, as well
Exhibits no as to promote
complications. secretion
Complies with movement into
treatment protocol larger airways
and prevention for
strategies. expectoration.
 Change
position to
 To facilitate
side lying
lung expansion
every 1-2
and provide
hours if
comfort to the
possible.
patient.

 To help clear
 Perform airway and
suctioning as expectorate
needed to secretions for a
remove patient who
secretions cannot do so.
from the
mouth and
trachea.
 To help expel
thin secretions
 Assist the and maintain
patient to the balance of
increase fluid the body fluids.
intake.
 To reduce
 Anticipate the shortness of
need for breath, increase
supplemental oxygen in
oxygen if the blood, and ease
BU-F-TC-41
Effectivity Date: Nov. 29,2013
Revision NO.:0
patient’s the amount of
condition work the heart
deteriorates. and lungs have
to do.\

Dependent:
 Administer the
medication  Patients receive
order of the medications
doctor. appropriate to
their clinical
needs.

BU-F-TC-41
Effectivity Date: Nov. 29,2013
Revision NO.:0

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