Philippine Rehabilitation Institute Foundation College of Nursing

Nursing Care Plan

Name: Hannah Jannelle A. Nierves Patient name: Diolata, Salvacion Cues
Subjective Cues

Diagnosis
Ineffective breathing pattern related to mucous secretions as manifested by crackle sounds

Planning
Long term: After 1hour of nursing intervention patient will breathe normally. Short term: After 30mins of nursing intervention patient will breathe normally.

Intervention
Monitor respiratory rate, depth, and effort

Rationale
Rapid, shallow respirations or dyspnea may be present because of hypoxia or fluid accumulation in abdomen. Indicates developing complications --presence of adventitious sounds reflects accumulation of fluid while diminished sounds suggest atelectasis-increasing risk of pulmonary infection.

Evaluation
After 30mins of nursing intervention the patient breaths normally.

Objectives Cues: Difficulty of breathing Fatigue Pale in appearance Crackles RR: 17

Auscultate breath sounds, noting crackles, wheezes, and rhonchi

Investigate changes in level of consciousness (LOC)

Changes in mentation may reflect hypoxemia and respiratory failure, which often accompany hepatic coma Facilitates breathing by reducing pressure on the diaphragm and minimizes risk of aspiration of secretions Aids in lung expansion and mobilizing secretions

Keep head of bed elevated. Position client on side

frequent repositioning, deepbreathing exercises, and coughing, as appropriate Monitor temperature. Note presence of chills, increased coughing, and changes in color or character of sputum

Indicative of onset of infection, such as pneumonia.

Monitor serial ABGs, pulse oximetry, vital capacity measurements , and chest xrays Provide supplemental oxygen (O2) as indicated.

Reveals changes in respiratory status and developing pulmonary complications May be necessary to treat or prevent hypoxia. If respirations or oxygenation are inadequate, mechanical ventilation may be required.

Philippine Rehabilitation Institute Foundation College of Nursing

Nursing Care Plan

Name: Hannah Jannelle A. Nierves Patient name: Sueno, Angelita Cues
Subjective Cues masakit yung kanang binti ko. As verbalized by the patient.

Diagnosis
Acute pain r/t fracture at the right leg as manifested by edema and pain scale of 7/10.

Planning
Long term: After 1hr of nursing intervention the patient will be relieved from pain. Short term:

Intervention
Perform a comprehensive assessment of pain to include location,characteri stics, onset, duration, frequency, quality, intensity orseverity, and precipitating factors of pain. Reduce or eliminate factors that precipitate or increase pain experience (e.g., fear, fatigue, monotony, and lack of knowledge)

Rationale
Pain is a subjective experience and must be described by theclient in order to plan effective treatment.

Evaluation
After 30mins of nursing intervention patient is relieved from pain.

Objectives Cues: Facial grimace. Weak in appearance. With edema. Redness in the right leg. Pain scale of 7/10

After 30mins of nursing intervention the patient will be relieved from pain.

Provide optimal pain relief with prescribed

Personal factors can influence pain and pain tolerance. Factorsthat may be precipitating or augmenting pain should be reduced or eliminated to enhance the overall pain management

analgesics.

program. To relieved pain.

Philippine Rehabilitation Institute Foundation College of Nursing

Nursing Care Plan

Name: Hannah Jannelle A. Nierves Patient name: Dipon, Ma. Cristina Cues
Subjective Cues masakit ang tahi ko. As verbalized by the patient.

Diagnosis
Acute pain r/t abdominal suture site as manifested by redness and pain scale of 7/10.

Planning
Long term: After 1hr of nursing intervention the patient will be relieved from pain. Short term: After 30mins of nursing intervention the patient will be relieved from pain.

Intervention
Perform a comprehensive assessment of pain to include location,characteri stics, onset, duration, frequency, quality, intensity orseverity, and precipitating factors of pain. Reduce or eliminate factors that precipitate or increase pain experience (e.g., fear, fatigue, monotony, and lack of knowledge)

Rationale
Pain is a subjective experience and must be described by theclient in order to plan effective treatment.

Evaluation
After 30mins of nursing intervention patient is relieved from pain.

Objectives Cues: Facial grimace. Weak in appearance. Redness in the suture site. Pain scale of 7/10

Provide optimal pain relief with prescribed

Personal factors can influence pain and pain tolerance. Factorsthat may be precipitating or augmenting pain should be reduced or eliminated to enhance the overall pain management

analgesics.

program. To relieved pain.