COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

NURSING CARE PLAN

Name of the Patient: Mrs. Diwata Bayani ___ Age: 68 yrs old Sex: Female Name of Student: Nicolas, Angela G. __________________
Civil Status: __ ____ Religion: _____________ Rm/Bed No. Area: Level/ Block: BSN 3B
Address: Date Submitted: 24/09/2022 _____________________________
Date of Admission: __ Diagnosis: Bronchiectasis Rating: ________________________________________________

Assessment (Cues) Nursing Diagnosis Nursing Objectives Nursing Interventions Rationale Evaluation

Objective Cues: Ineffective After 8 hours of Independent Interventions: After 8 hours of

- She has excessive breathing pattern independent, dependent, independent, dependent,
sputum related to increased and collaborative nursing and collaborative nursing
approximately 1 mucus production as interventions, the patient interventions, the goals
cup per day, evidenced by: will be able to: - Assess airway for - Maintaining patent airway were completely met and
tenacious, patency. is always the first priority, the patient was able to:
mucopurulent - She has - maintain clear, especially in cases like
- Lab test result excessive open airways as trauma, acute neurological - maintain clear,
says there are sputum evidence by normal decompensation, or open airways as
mucous plugging approximately breath sounds, cardiac arrest. evidence by
both lower lobes 1 cup per day, normal rate and normal breath
- Difficulty breathing tenacious, depth of sounds, normal
through her nose mucopurulent respirations. rate and depth of
as it is usually - Lab test result - classify methods to - Auscultate lungs for - Abnormal breath sounds respirations.
blocked says there are enhance secretion presence of normal or can be heard as fluid and - classify methods
mucous removal. adventitious breath mucus accumulate. This to enhance
plugging both sounds. may indicate ineffective secretion removal.
lower lobes airway clearance.
- Difficulty
breathing
through her
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nose as it is - Assess respirations. - A change in the usual

usually Note quality, rate, respiration may mean
blocked pattern, depth, flaring respiratory compromise.
- of nostrils, dyspnea on An increase in respiratory
exertion, evidence of rate and rhythm may be a
splinting, use of compensatory response to
accessory muscles, airway obstruction.
Scientific and position for
Explanation: breathing.
Progressively
deeper and
sometimes faster
breathing, followed - Note for changes in - Increasing
by a gradual mental status. lethargy, confusion,
decrease that restlessness, and/or
results in apnea. irritability can be initial
Reference: Jameson, signs of cerebral hypoxia.
L., Fauci, A., Kasper, Lethargy and somnolence
D., Hauser, S., are late signs.
Longo, D., Loscalzo,
J. (2018) Harrison's
Principles of Internal
Medicine (20th Ed.). - Note for changes in - Increased work of
U.S., McGraw-Hill HR, BP, and breathing can lead to
temperature. tachycardia
and hypertension.
Retained secretions or
atelectasis may be a sign
of an existing infection or
inflammatory process
manifested by a fever or
increased temperature.
COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

- Note presence of - Unusual appearance of

sputum; evaluate its secretions may be a result
quality, color, amount, of infection, bronchitis,
odor, and consistency. chronic smoking, or other
condition.

- Use pulse oximetry to

monitor oxygen - A discolored sputum is a
saturation; assess sign of infection; an odor
arterial blood gases may be
(ABGs) present. Dehydration may
be present if patient has
labored breathing with
thick, tenacious secretions
that increase airway
resistance.

- Teach the patient the

proper ways of - The most convenient way
coughing and to remove most secretions
breathing. (e.g., take a is coughing. So it is
deep breath, hold for necessary to assist the
2 seconds, and cough patient during this activity.
two or three times in Deep breathing, on the
succession). other hand, promotes
oxygenation before
controlled coughing.
-

- Position the patient - Upright position limits

upright if tolerated. abdominal contents from
Regularly check the pushing upward and
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patient’s position to inhibiting lung expansion.

prevent sliding down This position promotes
in bed. better lung expansion and
improved air exchange.

- Encourage patient to - Fluids help minimize

increase fluid intake to mucosal drying and
3 liters per day maximize ciliary action to
within the limits of move secretions.
cardiac reserve and
renal function.

- Educate patient on - Patient will understand the

coughing, deep underlying principle and
breathing, and proper techniques to keep
splinting techniques. the airway clear of
secretions.

- Provide patient
understanding about - Understanding
the proper use of prescriptions promote safe
prescribed and effective medication
medications and administration.
inhalers.

- Consider verbalization - Recognize reality of

of feelings. situation. Anxiety adds to
oxygen demand,
and hypoxemia potentiates
respiratory distress or
cardiac symptoms, which
in turn increases anxiety.
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Dependent Interventions:

- Salbutamol 2 puffs via - It works by relaxing the

spacer BID muscles of the airways
into the lungs, which
makes it easier to breathe.
- Nasonex and Sinus - Use to treat nasal
rinse daily to both congestion.
nostrils
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Independent Interventions:
Risk for falls
After 8 hours of
Risk Factors: After 8 hours of - Determine the client’s - These factors play a role independent nursing
independent nursing age, developmental in the client’s ability to interventions, the patient
- extremely lethargic Scientific interventions, the patient stage, health status, keep themselves safe from will be able to:
Explanation: will be able to: lifestyle, impaired injury. Nurses must
communication, thoroughly assess each of - not sustain a fall.
A widely accepted sensory-perceptual these factors when - relate the intent to
definition is “an - not sustain a fall. impairment, mobility, formulating a plan of care use safety
unplanned descent - relate the intent to cognitive awareness, or teaching the clients measures to
to the floor with or use safety and decision-making about safety measures. prevent falls.
without injury to the measures to ability.
patient.” The nursing prevent falls.
diagnosis for risk of - Assess the client’s - Alterations in mobility
falls is “increased ability to ambulate and secondary
susceptibility to falling identify the risk for to muscle weakness,
that may cause falls. paralysis, poor balance,
physical harm. and lack of coordination
Reference: Jameson, increase the risk of falls.
L., Fauci, A., Kasper,
D., Hauser, S., - Conduct safety - Nurses perform an
Longo, D., Loscalzo, assessment in the environmental risk
J. (2018) Harrison's client’s home or care assessment to determine
Principles of Internal setting. the presence of objects or
Medicine (20th Ed.). items (e.g., cord, hooks)
U.S., McGraw-Hill that could potentially be
used in suicidal hanging.
Therefore, it should be
removed to ensure the
client’s safety.
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- Guide the patient to - The patient should be

their surroundings. familiar with the layout of
Put the call light within the environment to prevent
reach and teach how accidents from happening.
to call for assistance. Items that are too far from
the patient may cause
hazards.

- Utilize alternatives to - Alternatives to restraints

restraints that can be may include alarm
used to prevent falls systems with ankle or wrist
and injuries. bracelets, alarms for bed
or wheelchairs, close and
frequent monitoring of the
patient, locked doors to
the unit, keeping the bed
low, etc.

- If a patient is notably - Special beds can be an

disoriented, consider efficient and useful
using a special safety alternative to restraints
bed that surrounds the and help keep the patient
patient. If a patient safe during periods of
has a traumatic brain confusion and anxiety.
injury, use the Emory
cubicle bed.

- Ask family or - This is to prevent the

significant others to be patient from accidental
with the patient to injury, falling, or pulling out
prevent the incidence tubes.
of accidental falling or
pulling out tubes.
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- Place the patient in a - Moving the client’s room

room near the nurses’ closer to the nurse station
station. allows the health care
provider to closely observe
patients at high risk for
injury and falls and
promptly provide
interventions.

- Validate the patient’s - Such identification is vital

feelings and concerns for patients at risk for
related to injury, especially those
environmental risks. with dementia, seizures, or
other medical disorders.

- -