ST.

ANTHONY’S COLLEGE
Nursing Department

NURSING CARE PLAN

Name of patient: D.C.O. Attending Physician: Dr.B.

Age: 87 yrs. old Ward/Bed #: Medical Ward 3007-2 Impression Diagnosis:CAP,
Hypertensive urgency, HCVD, COPD

Clustered Cues: Nursing Rationale Outcome Criteria Nursing Rationale Evaluation

Diagnosis Interventions
Ineffective Normally the lungs Short term:  Establish  to gain client’s
SUBJECTIVE: Airway are free from rapport and relatives
Clearance related secretions. After 1 hour of trust The client shall
“Nabudlayan ko to retained Pneumonia bacteria nursing have
mag ginhawa. Di ko secretions in the are invading the intervention, the  Monitor VS  to obtain maintained
mapaguwa bronchi lung parenchyma client will be able baseline data airway patency,
kamayad plemas ko secondary to thus, producing to maintain clear breath
mong.” as pneumonia inflammatory airway patency,  Suction  to decrease sounds
verbalized by the process. And these clear breath secretions secretion (goal partially
patient. responses leading to sounds. PRN retained in the met)
filling of the bronchi
alveolar sacs with
OBJECTIVES: exudates leading to Long Term:  Place on  to maintain The client have
consolidation. The orthopneic patent airway expectorated
 DOB airway is narrowed After 1 day of position retained
 Wheezes on thus wheezes is nursing secretions and
both lung being heard. DOB in intervention, the  Elevate HOB  to take maintained
fields some cases client will be able advantage of normal
Productive Cough orthopnea is to expectorate the gravity breathing
observed. retained decrease pattern
secretions and pressure on (goal met)
maintain normal the diaphragm.
breathing pattern.
  Encourage
deep  to mobilize
breathing secretion

 Give  to moisten
bronchodilator secretions for
as ordered easy
expectoration

 Refer for any

abnormal  to medically
changes in manage any
the body complications.

Student’s Name: Cen Janber A. Cabrillos

Clinical Instructor: Jerry V. Able, RN, MAN