NCP #1 ACUTE PAIN RELATED TO DECREASED BLOOD SUPPLY

NURSING SCIENTIFIC EXPECTED

ASSESSMENT PLANNING INTERVENTIONS RATIONALE
DIAGNOSIS EXPLANATION OUTCOME

Subjective: Acute Pain Coronary artery Short Term: 1. Observe nonverbal 1. Observations Short Term:
“Sumasakit parin related to disease (CAD) is a After 5-6 cues and pain may not be The patient
paminsan-minsan decreased condition in which hours of behaviors. congruent with shall have
ung dibdib ko lalo blood supply plaque builds up nursing verbal reports. used non-
na pag gumagalaw” in the heart as inside the coronary interventions, pharmacologi
as verbalized by the evidenced by arteries. Coronary the patient 2. Maintain quiet, 2. Mental/ c treatments
patient. (11-28- chest pain. arteries are arteries will use non- comfortable emotional stress for chest
2018) that supply the pharmacologi environment. increases pain.
heart muscle with c treatments Restrict visitors as myocardial
oxygen-rich blood. for chest pain. necessary. workload.
Objective: Plaque is made up of Long Term:
The patient fat, cholesterol, 3. Provide light meals. 3. Decreases The patient
manifested: calcium, and other Long Term: Have patient rest for myocardial shall have
 Chest pain (7/10) substance found in the After 1-2 days 1 hour after meals. workload been free
(11-28-2018) blood. Plaque of nursing associated with from chest
 Difficulty of narrows the arteries interventions, work of pain and
breathing and reduces blood the patient digestion, maintained
 Pallor flow to your will be free reducing risk of vital signs
 Weakness noted heart muscle. It also from chest anginal attack. within
with limited makes it more likely pain and normal range.
ROM that blood clots will maintain vital
 Cool lower form in your arteries. signs within
extremities Blood clots can normal range.
 Decreased partially or 4. Provide comfort 4. To promote non-
HGB (88 g/L), completely block measures such as pharmacological
HCT (0.28%) blood flow. When positioning the management for
and the coronary patient to desired pain.
RBC arteries are narrowed comfort.
 (2.8x10^9/L) or blocked, oxygen-
 Vital signs taken rich blood can’t reach 5. Instruct and
as follows: the heart muscle. encourage the use of 5. To distract
T: 36C P: relaxation attention and
82BPM R: techniques such as reduce tension.
22CPM BP: deep breathing
110/70mmHg exercise.
Patient may
manifest: 6. Increases oxygen
 Hypoxia 6. Provide available for
 Restlessness supplemental myocardial
 Confusion oxygen if indicated. uptake and
 Dizziness reversal of
 Grimace ischemia.
 Weak pulse
7. To evaluate
7. Encourage coping abilities
verbalization of and to identify
feelings about the areas of
pain. additional
concern.

8. To treat and
8. Administer anti- prevent anginal
anginal medications pain.
promptly as
indicated.
NCP #2 IMPAIRED GAS EXCHANGE RELATED TO ALTERED OXYGEN CARRYING CAPACITY

NURSING SCIENTIFIC EXPECTED

ASSESSMENT PLANNING INTERVENTIONS RATIONALE
DIAGNOSIS EXPLANATION OUTCOME

Subjective: Ø Impaired gas An infection Short Term: 1. Note respiratory 1. Provides Short Term:
exchange r/t triggers alveolar After 3-4 hours rate, depth, use of insight into The patient shall
Objective: altered oxygen inflammation and of nursing have improved
accessory muscle, the work of
The patient carrying edema. This interventions, and maintained
manifested: capacity of produces an area of the patient will pursed lip breathing and ventilation an
 Difficulty of blood as low ventilation with be able to breathing, area of adequacy of adequate
breathing evidenced by normal perfusion. improve and pallor/cyanosis. alveolar oxygenation of
 Pallor pallor, Capillaries become maintain ventilation. tissues.
 Productive cough decreased engorged with ventilation and
 Limited ROM hemoglobin, blood, causing adequate 2. Auscultate breath 2. Abnormal
 Cool lower hematocrit, stasis. As the oxygenation of
sounds note areas breath sounds
extremities RBC, presence alveolocapillary tissues.
of crackles, membrane breaks of decreased/ are indicative
 Decreased adventitious breath numerous
HGB (88 g/L), DOB, down, alveolus fills Long Term:
HCT (0.28%) weakness and with blood and Long Term: sound as well as problems. The patient shall
and fatigue. exudates, resulting After 2-3 days of fremitus. have
RBC in atelectasis. nursing demonstrated
(2.8x10^9/L) Shrunken alveoli interventions, 3. Assess level of 3. Decreased absence of
can’t accomplish the patient will symptoms of
 Vital signs taken consciousness. level of
gas exchange. be able to respiratory
as follows: T: consciousness distress.
demonstrate
36.2C P: 86BPM can be an
absence of
R: 18CPM BP:
symptoms of indirect
130/80mmHg
respiratory measurement
Patient may
distress. of impaired
manifest:
 Hypoxia oxygenation
 Restlessness
 Confusion
 Dizziness 4. Elevate head of 4. Elevation or
 Cyanosis bed and position upright
 Weak pulse client position
appropriately. facilitates
respiratory
function by
gravity.
5. Encourage
adequate rest and 5. Helps limit
limit activities to oxygen needs
within client and
tolerance. oxygenation.

6. Monitor body
temperature, as 6. High fever
indicated. greatly
increase
metabolic
demands and
oxygen
consumption
and alters,
cellular
oxygenation.
7. Assess the
patient’s ability to
7. Retained
cough out
secretions
secretion.
weaken gas
exchange.
8. Evaluate the
patient’s hydration 8. Insufficient
status. hydration may
reduce the
ability to clear
secretions.

9. Maintain 9. Oxygen
supplemental saturation
oxygen therapy, as should be kept
needed. at 90% or
greater. To
relieve
difficulty of
breathing.
NCP #3 INEFFECTIVE AIRWAY CLEARANCE RELATED TO RETAINED SECRETIONS

NURSING SCIENTIFIC EXPECTED

ASSESSMENT PLANNING INTERVENTIONS RATIONALE
DIAGNOSIS EXPLANATION OUTCOME

Subjective: Ineffective Due to the presence Short Term: 1. Assess respiratory 1. To determine Short Term:
“Nahihirapan airway of microorganisms, After 3-4 hours function e.g. accumulation of The patient
akong huminga clearance there is an increased of nursing shall have
breath sounds, rate secretions/
minsan kase related to production and interventions, demonstrated
parang may plema retained accumulation may the patient will rhythm, and depth inability to effective
ako sa lalamunan” secretions as obstruct the smooth be able to and use of clear airways clearing of
as verbalized by evidenced by flowing of air in and demonstrate accessory muscles. that may lead to secretions.
the patient. the presence of out of the lungs. effective ways use of
crackles and With this blockage, a to clear accessory
Objective: difficulty of patent airway is secretions. muscles and
The patient breathing. difficult to maintain,
increase work
manifested: this results in
 Pallor decreased volume of Long Term: 2. Note ability to of breathing. Long Term:
 Productive inspired air resulting After 2-3 days expectorate The patient
cough, unable to an impaired of nursing mucous/cough 2. Expectoration shall have
to expectorate oxygen exchange interventions, effectively. may be difficult demonstrated
 Difficulty of within the alveoli of the patient will when secretions absence of
breathing the lungs resulting to be able to are very thick. congestion
 Presence of a lower oxygen demonstrate
3. Document
with clear
crackles supply for the rest of absence of breath sounds.
the body. congestion with character, and 3. To obtain
 Vital signs
clear breath amount of sputum. baseline data.
taken as
follows: T: sounds.
36.2C P: 4. Place patient in
86BPM R: semi or high 4. Positioning
18CPM BP: fowler’s position. help maximize
130/80mmHg Assist patient with lung expansion
and decrease
Patient may coughing and deep respiratory
manifest: breathing exercise. effort.
 Palpitations 5. Maintain fluid
 Orthopnea intake. 5. High fluid
 Weak pulse intake helps to
 Hypoxia
thin secretions,
making them
easier to
expectorate.
6. Encourage warm
versus cold 6. To facilitate
liquids. expectoration
of secretions.
7. Provide
opportunity for 7. To prevent
rest. fatigue and
decrease
oxygen
consumption.
8. Suction nose,
mouth, and trachea 8. To clear airway
prn. when excessive
or viscous
secretions are
blocking
airway.

9. Insert oral airway 9. To maintain

when needed. anatomical
 position of
natural airway,
if laryngeal
edema may
block airway.

10. Refer to support 10. For treatment

groups, determine of obstructive
that client has sleep apnea,
equipment and is when indicated.
informed in use of
nocturnal
continuous
positive airway
pressure (CPAP).
NCP #4 RISK FOR DECREASED CARDIAC OUTPUT RELATED TO ALTERED AFTERLOAD AND PRELOAD

SCIENTIFIC
NURSING EXPECTED
ASSESSMENT EXPLANATIO PLANNING INTERVENTIONS RATIONALE
DIAGNOSIS OUTCOME
N

Subjective: Ø Risk for Coronary artery Short Term: 1. Assess heart rate 1. Most patients Short Term:
decreased disease (CAD) is After 5 hours of and blood pressure. have The patient will
Objective: cardiac output a condition in nursing compensatory be shall have
The patient related to which plaque interventions the tachycardia maintained
manifested: altered preload builds up inside patient will be and adequate
 Hypotension and afterload the coronary able to maintain significantly cardiac output
(110/70) as evidenced arteries. Coronary adequate cardiac low blood as evidenced
 Pallor by arteries are output as pressure in by blood
 Cool lower hypotension, arteries that evidenced response to pressure, pul
extremities fatigue and supply the by blood reduced se rate and
 Difficulty of pallor. heart muscle with pressure, pulse cardiac rhythm and
breathing oxygen- rate and rhythm output. within normal
 Decreased rich blood. Any and within parameters.
HGB (88 g/L), occlusion in the normal 2. Check for 2. Weak pulses
HCT (0.28%) artery causes parameters. peripheral pulses, are present in Long term: The
and decreased blood including capillary reduced strok patient shall
RBC supply resulting Long term: refill. e volume and have
(2.8x10^9/L) into decreased After 2-3 days of cardiac demonstrated
 CRT <2s venous return and nursing output. ability to
decreased amount interventions the Capillary tolerate activity
 Vital signs taken
of blood expelled patient will be refill is without
as follow: T: 36C
by the ventricles. able to sometimes symptoms of
P: 82BPM R:
demonstrate slow or dyspnea.
22CPM BP:
ability to tolerate absent.
110/70mmHg
activity without 3. Note respiratory
 Patient may
symptoms of rate, rhythm, and 3. Shallow, rapid
manifest:
dyspnea. breath sounds. respirations
 Hypoxia Identify any are
 Bradycardia presence of characteristics
 Cyanosis paroxysmal of decreased
 Restlessness nocturnal dyspnea cardiac
 Confusion (PND) or output.
 Dizziness orthopnea. Crackles
 Grimace indicate fluid
 Paroxysmal buildup
Nocturnal secondary to
Dyspnea impaired left
ventricular
 Weak pulse
emptying.

4. Assess for reports of

fatigue and reduced 4. Fatigue and
activity tolerance. exertional
dyspnea are
common
problems with
low cardiac
output states.
Close
monitoring of
the patient’s
response
serves as a
guide for
optimal
progression of
5. Closely monitor activity.
fluid intake
including IV lines. 5. Poorly
Maintain fluid functioning
restriction if ventricles may
ordered. not tolerate
 increased
fluid volumes.

6. Position patient in
semi-Fowler’s to 6. Upright
high-fowler’s. position is
recommended
to reduce
preload and
ventricular
filling when
fluid overload
is the cause.
7. Monitor bowel
function. Provide 7. Decreased
stool softeners as activity can
ordered. Tell patient cause constipa
to avoid straining tion. Straining
when defecating. when
defecating
that results in
the Valsalva
maneuver can
lead to
dysrhythmia,
decreased
cardiac
function, and
sometimes
death.
8. Maintain oxygen 8. The failing
therapy as heart may not
prescribed. be able to
respond to
increased
oxygen
demands.
Oxygen
saturation
need to be
greater than
90%.

9. Refer to ND’s risk 9. To determine

for cardiac Tissue existing
Perfusion. complication.
NCP #5 INEFFECTIVE TISSUE PERFUSION RELATED TO DECREASED HEMOGLOBIN, HEMATOCRIT, AND RBC

NURSING SCIENTIFIC ECPECTED

ASSESSMENT PLANNING INTERVENTIONS RATIONALE
DIAGNOSIS EXPLANATION OUTCOME

Subjective: Ineffective Hemoglobin is a Short Term: 1. Assessed and 1. To determine Short Term:
“Hinihingal ako Tissue complex protein-iron After 5 hours of monitored Vital circulatory The patient
pag gumagalaw Perfusion compound in the nursing Signs, skin color, status and shall have
tsaka pag related to blood that contains interventions the and temperature. adequacy of demonstrated
nagsasalita ng decreased oxygen to the cells patient will be perfusion. behaviors to
matagal” as Hemoglobin, from the lungs and able to improve
verbalized by the Hematocrit, carbon dioxide away demonstrate 2. Elevate head of 2. To promote circulation such
patient. and RBC as from the cells to the behaviors to bed to 30 degrees. venous return. as engaging in
evidenced by lungs. Transport of improve passive range
Objective: pallor, fatigue, oxygen is impaired to circulation such of motion
The patient and body anemia and hypoxia as engaging in exercises.
manifested: malaise. may develop. The passive range of 3. Monitor laboratory 3. It is critical to
 Pallor body then attempts to motion values. compare serial
 Fatigue compensate for tissue exercises. laboratory
 Decreased hypoxia by values to Long Term:
HGB (88 g/L), increasingly cardiac Long term: evaluate The patient
HCT (0.28%) output and re After 2-3 days of progression or shall have
(11-27-18) and distributing blood nursing deterioration achieved a
RBC from tissues of low interventions the in the client normal
(2.8x10^9/L) oxygen needs. patient will be and to identify laboratory
 CRT <2s able to achieve a changes result.
 Difficulty of normal before they
breathing laboratory result. become
 Vital signs potentially
taken as life-
follows: T: threatening.
36.2C P:
86BPM R: 4. Note nutritional 4. Dehydration
and fluid status. can reduce
 18CPM BP: blood volume
130/80mmHg and
compromise
Patient may peripheral
manifest: circulation.
 Palpitations
 Orthopnea 5. Assessed for 5. Indicates
 Weak pulse reports of deep / decreased
throbbing cues and perfusion.
numbness.

6. Identify necessary 6. To promote

changes in lifestyle independence,
and assist client to enhances self
incorporate disease concept.
management into
activities of daily
living.

7. Recommend foot
or ankle exercises 7. To reduce
when client was venous
unable to ambulate pooling and
freely. increased
venous return.
8. Review laboratory
studies. 8. To determine
probability,
location, and
degree of
impairment.
9. Refer to ND’s for
Peripheral
Neurovascular 9. To provide
Dysfunction. additional
interventions
as appropriate.
NCP #6 FATIGUE RELATED TO DECREASED METABOLIC ENERGY PRODUCTION

NURSING SCIENTIFIC EXPECTED

ASSESSMENT PLANNING INTERVENTIONS RATIONALE
DIAGNOSIS EXPLANATION OUTCOME

Subjective: Fatigue Anemia is the most Short Term: 1. Assess the client’s 1. Fatigue can limit Short Term:
“Nanghihina ako related to common hematologic After 5-6 ability to perform the client’s The patient
palagi at yung decreased disorder in which hours of activities of daily ability to shall have
asawa ko nalang metabolic the hemoglobin level nursing living (ADLs), and participate in participated
yung gumagawa ng energy is lower than normal, interventions, the demands of self-care and in the use of
gawain para sakin” production as reflecting the the patient daily living. perform his or energy
as verbalized by the evidenced by presence of a decrease will her role conservation
patient. lack of in number or participate in responsibilities principles.
energy, body derangement in the use of in family and
Objective: malaise and function of energy society, such as Long Term:
The patient pallor red blood cells within conservation working outside The patient
manifested: the circulation. As a principles. the home. shall have
 Pallor result, the amount of 2. Assist the client in demonstrated
 Difficulty of oxygen delivered to planning and 2. This will allow reduction
breathing body tissues and Long Term: prioritizing the client to of fatigue, as
 Cool lower organs is also After 2-3 days activities of daily maximize his/her evidenced by
extremities lessened, making of nursing living (ADL). time for reports of
 Decreased them to function interventions, accomplishing increased
HGB (88 g/L), improperly. the patient important energy and
HCT (0.28%) will activities. ability to
and demonstrate perform
RBC reduction 3. Monitor laboratory 3. It is critical to desired
(2.8x10^9/L) of fatigue, as results. compare serial activities
 Vital signs taken evidenced by laboratory values such as am
as follow: T: 36C reports of to evaluate care, dressing
P: 86BPM R: increased progression or and feeding.
20CPM BP: energy and deterioration in
110/70mmHg ability to the client and to
perform identify changes
Patient may desired before they
manifest: activities such become
 Hypoxia as am care, potentially life-
 Cyanosis dressing and threatening.
 Restlessness feeding.
 Confusion 4. Organization and
 Grimace time
 Paroxysmal 4. Educate energy- management can
Nocturnal conservation help the client
Dyspnea techniques. conserve energy
and
 Weak pulse
reduce fatigue.

5. Oxygen
saturation should
5. Provide be kept at 90% or
supplemental greater. To
oxygen therapy, as relieve difficulty
needed. of breathing.

6. A plan that
balances periods
of activity with
6. Assist the client in periods of rest
developing can help the
a schedule for daily client complete
activity and desired activities
rest. Stress the without adding
importance of levels to fatigue.
frequent rest
periods. 7. To receive
appropriate
 intake of fats,
7. Collaborate with carbohydrates
dietician. and provides as
energy
resources.
NCP #7 IMPAIRED PHYSICAL MOBILITY RELATED TO DECREASED MUSCLE STRENGTH

NURSING SCIENTIFIC EXPECTED

ASSESSMENT PLANNING INTERVENTIONS RATIONALE
DIAGNOSIS EXPLANATION OUTCOME

Subjective: Impaired Impaired physical Short Term: 1. Determine factors 1. To be able to Short Term:
“Nanghihina ako physical mobility can be a After 3-4 that contributes to determine the The patient
palagi at yung mobility result of disease or hours of immobility. origin and plan shall have
asawa ko nalang related to during rehabilitation nursing 
 an effective verbalized
yung gumagawa ng decreased process. For example, interventions, understandin
treatment.
gawain para sakin” muscle post-op surgeries, the patient g of situation
as verbalized by the strength. trauma, multiple will be able to 2. Assess patient’s about
patient. sclerosis, morbid verbalize motor skills, ease 2. To know if the individual
and capability of patient is moving
obesity, stroke, understandin treatment
movement. towards the
Objective: fracture etc. In the g of situation regimen and
expected
The patient patient’s case, she is about safety
outcome or if it is
manifested: advised to be on individual measures.
the opposite.
 Pallor complete bed rest treatment
3. Encourage adequate
 Difficulty of without bathroom regimen and
intake of fluids and 3. So the patient
Long Term:
breathing privileges because of safety
nutritious foods. can still be
The patient
 Limited ROM her existing condition. measures.
normal in terms
shall have
 Dependence on of nutritional
demonstrated
self care Long Term: techniques or
status.
 Vital signs taken After 2-5 4. Provide regular skin behaviors that
as follow: T: 36C days of examination and enable
P: 86BPM R: nursing care especially in 4. To resumption of
avoid
20CPM BP: interventions, reddened areas. activities.
pressure / bed
110/70mmHg the patient
ulcers.
will be able to 5. Encourage in
Patient may demonstrate participation in self-
manifest: techniques or care. 5. To ensure that the
 Hypoxia behaviors that
 Cyanosis enable client can 
 still
 Restlessness do ADLs and
 Confusion resumption of can still be
activities. independent. 

NCP #8 SELF CARE DEFICITY RELATED TO WEAKNESS

NURSING SCIENTIFIC EXPECTED

ASSESSMENT PLANNING INTERVENTIONS RATIONALE
DIAGNOSIS EXPLANATION OUTCOME

Subjective: Self-Care Self-Care Deficit: Short Term: 1. Determine factors 1. To be able to Short Term:
“Nanghihina ako Deficity Impaired ability to After 3-4 that contributes to determine the The patient
palagi at yung related to perform or complete hours of immobility. origin and plan shall have
asawa ko nalang weakness activities of daily nursing 
 an effective verbalized
yung gumagawa ng living for oneself, interventions, initiative on
treatment.
gawain para sakin” such as feeding, the patient providing
as verbalized by the dressing, bathing, will be able to 2. Assess patient’s self-care such
motor skills, ease 2. To know if the
patient. toileting. verbalize as am care,
and capability of patient is moving
She is unable to take initiative on dressing and
movement. towards the
Objective: care of herself due to providing feeding.
expected
The patient her existing condition. self-care such
outcome or if it is
manifested: as am care,
the opposite.
 Pallor dressing and
3. Assess the
 Difficulty of feeding.
perceived impact of 3. This necessitates
breathing change in ADLs, support to work
 Limited ROM social participation, through to
 Cool lower personal optimal
extremities relationships, and resolution.
 Dependence on occupational
self care Long Term: Long Term:
After 2-5 activities. 
 The patient
 Vital signs taken
as follow: T: 36C days of shall have
4. Encourage adequate 4. So the patient
P: 86BPM R: nursing participated
intake of fluids and can still be
20CPM BP: interventions, in activities
nutritious foods. normal in terms
110/70mmHg the patient on self-care
of nutritional
will be able to such as am
status.
Patient may participate in care, dressing
manifest: activities on and feeding.
 Hypoxia self-care such 5. Provide regular skin
 Restlessness as am care, examination and 5. To avoid
 Irritability dressing and care especially in pressure / bed
 Confusion feeding. reddened areas. ulcers.
 Weak pulse

6. Encourage in
participation in self- 6. To ensure that the
care. client can 
 still
do ADLs and
can still be
independent.