NURSING CARE PLAN-1

Patient Name: - Rab Dino S/O Mola Bux Age: 50Y Sex: Male Ward No: 12 Bed No: 12 Marital Status: Married
Medical Diagnoses: Bronchitis Address: SAKRAND OCCUPATION: Farmer Date: 19--03-2007

ASSESSMENT NURSING PLANNING INTERVENTION SCIENTIFIC RATIONALE EVALUATION

DIAGNOSIS
Ineffective SHORT TERM: • Assess respiratory rate, • Useful in evaluating the • Patient
SUBJECTIVE: airway After 8 hours of depth. Note use of accessory degree or respiratory distress display
clearance nursing interventions muscles, pursed lip and chronicity of the disease improved
I’m having related to the patient will: breathing, Inability to speak. process. ventilation and
difficulty excessive, • Demonstrate • Elevate head of the bed, • Oxygen delivery may be adequate
breathing as thickened improved assist patient assume improved upright position and oxygenation of
verbalized by mucous ventilation and position to ease work of breathing exercises to tissues and
the patient. secretions. adequate breathing. Encourage deep decrease airway collapse, Arterial blood
oxygen. slow or pursed lip breathing dyspnea and work of gases (ABGs)
• Arterial blood as individually tolerated or breathing. within normal
gases (ABGs) indicated. range and free
within normal • Routinely monitor skin and • Cyanosis may be peripheral in from symptoms
range. mucous membrane color. nail beds or central inlips or of respiratory
• No signs of earlobes. Duskiness and distress.
respiratory central cyanosis indicate
OBJECTIVE: distress. advanced hypoxemia.
• Presence of • Encourage expectoration of • Thick, tenacious, copious
rhonchi. sputum; suction when secretions are major source
• Ineffective LONG TERM: indicated. ineffective airways. Deep
cough. After months of suctioning may be required
• V/S taken nursing interventions, when cough is ineffective for
as the patient: expectoration of secretions.
follows: • Ventilation or • Evaluate level of activity • During severe acute
T: 37.2 oxygenation tolerance. Provide calm and respiratory distress, patient be
P: 79 is adequate to quiet environment. totally unable Perform basic
R: 24 meet self care care activities because of
BP: 110/80 needs. hypoxemia and dyspnea.
• Evaluate sleep patterns, note • Multiple external stimuli and
report of difficulties and presence of dyspnea may
whether patient feels well prevent relaxation and inhibit
rested. sleep.
• Monitor vital signs and • Tachycardia, dysrhythmias,
cardiac rhythm. changes in blood pressure can
effect of systemic hypoxemia
on cardiac function.
Reference:
Carpenito. L .J. (1995). Nursing Diagnosis (6th Ed.), New Jersey J.B.Lippincott Company.
Student name: Akbar Ali Arain Discipline B.Sc. N-1(2007-9)