NURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTIO RATIONALE EVALUATIO

N N
Subjective:  Diarrhea Diarrhea or  Plan of  Observe  It  Client’
Abdominal pain Related to frequent care and and could s
Bowel urgency; ingestion of passing of who record help respon
cramping suspected loose, watery involved the deter se to
contaminat stool is not frequenc
in mine treatm
ed food. y,
really a disease planning the ent,
amount,
Objective: but a condition . time, and causa teachi
 Hyperacti due to  Teachin character tive ng,
ve bowel underlying g plan. istics of factor and
sounds. factors or stool and and action
 Loose diseases. One for any the s
liquid risk factor is presence need perfor
stools >3 the ingestion of for med.
in 24 food with the precipitati additi  Attain
hours presence of ng onal ment
microorganism factors.
hydrat or
s like V.  Restrict
ion progre
foods as
cholera, replac ss
indicated
Salmonella like foods ement toward
typhi and containin . desire
others. These g  These d
organisms caffeine, foods outco
could adhere to too much can me(s)
the gut wall, oil, fiber, add  Modifi
alter the milk, and more cation
acidity, and fruits. irritati s to
irritate the  Provide a on to plan of
gastrointestinal quiet and
the care.
tract. non-
stimulatin stoma
 g ch.
environm  Stress
ent and can
teach trigger
client of
freque
relaxation
technique nt
s to passi
decrease ng of
stress. stools
 Start ; with
venoclysi these
s and meas
intraveno ures,
us stress
replacem could
ent as
be
indicated.
avoid
ed or
reliev
ed.
 Hydra
ting
the
client
helps
replac
e the
fluid
and
electr
olyte
he
loose
 from
diarrh
ea.

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTIO RATIONALE EVALUATIO

N N
Subjective:  Constipatio  Hirschsp  Plan of  Encourag  Suffici  Patien
 Frequenc n related to rung’s care/inte e the ent t
y less changes in disease rvention patient to fluid is respon
than usual digestive (congeni s and take in neede ses to
process. fluid 2000 d to
pattern tal changes treatm
to 3000 keep
 Reported aganglio in mL/day, if the
ent
feeling of nic lifestyle not fecal regime
abdominal megacol that are contraindi mass n.
or rectal on) is necessa cated soft.  Chang
fullness or the ry to medically But e
pressure. congenit correct . take bowel
[(Less than al individua  Assist note of patter
usual amount absence l patient to some n,
of stool] of or situation take at patient charac
[Nausea] arrested . least 20 g s or ter of
of dietary older
develop stool
fiber patient
Objective: ment of s  Attain
(e.g., raw
 Hard- parasym fruits, having ment/p
formed pathetic fresh cardio rogres
stools ganglion vegetable vascul s
 Straining cells in , whole ar toward
 at stool the grains) limitati desire
 Palpable intestinal per day. ons d
mass wall,  Encourag requiri outco
usually ea ng me(s)
 Decrease
regular less
d activity in the
period for fluid
level, distal intake.
eliminatio
[Immobilit colon. n.  Fiber
y] Sympto adds
[Decrease ms are bulk to
d bowel related the
sounds] to stool
[Abdomin chronic and
al intestinal makes
distention] obstructi defeca
on and tion
usually easier
becau
appear
se it
shortly passe
after s
birth but throug
may not h the
be intesti
recogniz ne
ed until essent
later in ially
childhoo uncha
d or nged.
(rarely)  Most
people
in
defeca
adulthoo te
d. In this followi
order ng the
the lack first
 of daily
colorect meal
al or
innervati coffee,
as a
on.
result
of the
gastro
colic
reflex.

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTIO RATIONALE EVALUATIO

N N
Subjective:  Fatigue   Short  Assist the  A plan  After 1
  Insufficien related term patient to that hour
t energy; tophysiolog goal: develop a balanc of nursi
impaired ical factor: Within 1 schedule es ng
ability to Pregnancy hour for daily period interve
activity s ntions,
maintain of nursin
and rest. of acti the
usual g
 Encourag vity client
routines intervent e the with identifi
or usual ions, the patient to period ed
physical client use s basis
activity. will assistive of rest of
 Tiredness; identify devices can fatigue.
nonrestor basis of (eg: help  After 8
ative fatigue. trochante the hours
sleep  Long rrolls) patient of nursi
term  Assess compl ng
pattern.
the ete interve
 Guilt goal:
patient’s desire ntions,
about Within 8 d the
ability to
difficulty hours perform activiti client
maintainin of nursin activities es reporte
g g of daily withou d
responsibi intervent living(AD t improv
lities. ions, the Ls). adding ed
 Increase client  Assess to sense
will the levels of ener
in physical
report patient’s of fatig gy.
symptoms ue
improve emotional
, rest  The
d sense response
requireme use
of energ to
nts. fatigue. of assi
Objective: y. stive
 Assess
 Alteration the device
in patient’s s can
concentrat nutritional minimi
ion intake ze
 Apathy, of calorie energy
lethargy; s, expen
listlessnes protein, diture
s; minerals, and
and preven
drowsines
vitamins. t injury
s with
 Disinteres activiti
t in es.
surroundi  Fatigu
ngs; e can
introspecti limit
on. the
person
’s
ability
to
partici
pate in
self-
care
and
perfor
m his
or her
role
respon
sibilitie
s.
 NURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTIO RATIONALE EVALUATIO

N N
Subjective:  Nutrition  Nausea  After 3 Independent: Inflammation  After 3
“Nagsusuka ako” imbalance and days. Of • Auscultate or irritation of days.
as verbalized by d less than vomiting nursing bowel the intestine Of
patient. body are not interventi sounds, noting may be nursing
requireme diseases ons, the absence or accompanie interve
nts related , but client will ntions,
Objective: hyperactive d
to nausea rather be able the
 Hyperactiv sounds. by intestinal
and are to client
e bowel
vomiting. symptom maintain • Eliminate hyperactivity, will be
sounds. smells diminished
s of usual able to
 Pale many weight. from the water maintai
conjunctiv different . environment. absorption n usual
a and condition • Avoid foods and weight.
mucus s, such that diarrhea.
membrane as
. might cause or •Reduces
infection
 V/S taken ("stomac exacerbate gastric
as follows: h flu"), abdominal stimulation
T: 36.6 food cramping like and
PR: 98 poisonin caffeinated vomiting
R: 18 g,
beverages, response.
BP: motion
sickness
chocolate, •Might
110/90
, orange increase
overeati juice. abdominal
ng, • Measure cramping.
blocked abdominal •Provides
intestine, girth. quantitative
illness, •Observe skin evidence of
concussi or changes in
on or mucous gastric or
brain membrane intestinal
injury,
dryness, and distention.
appendic
itis, and
turgor. Note •Hypovolemi
migraine peripheral a, fluid shifts
s. edema and
Nausea and sacral nutritional
and edema. deficits
vomiting •Assess contribute to
can abdomen poor skin
sometim frequently for turgor,
es be return to edematous
symptom softness, tissue.
s of
appearance of •Indicates
more
serious
normal bowel return
diseases sounds, and of normal
such as passage of bowel
heart flatus. function and
attacks, •Weigh daily. ability to
kidney or Collaborative resume oral
liver intake.
disorder •Monitor BUN, •Initial losses
s, central protein, or
nervous prealbumin or gains reflect
system
albumin, changes in
disorder
s, brain
glucose, hydration.
tumors, nitrogen •Reflects
and balance organ
some as indicated. function and
forms of • Advance diet nutritional
cancer. as status and
tolerated. needs.
•Careful
progression
of
diet when
intake is
resumed
reduces risk
of
gastric
. irritation.
 NURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTIO RATIONALE EVALUATIO

N N
Subjective: cute back pain Independent:  After 3



P- low
back pain
Q- aching
related to
pressure After  Assessed
pain,
character
Pain days.
Of
nursing
on lumbar nerve



R- whole
abdomen
S- 8/10T-
endings
secondary 8 , location,
severity,
and
asse interve
ntions,
the
to enlargement
restless

Objective:
of
the outpouching hours duration;
used a
pain
ssm client
will be
able to
abdominal aortic
of ent
rating maintai
 Facial aneurysm scale. n usual
mask of
Acute back pain  Accepted weight.
pain
related to
nursi can
client’s
 Reports of
pain pressure on descriptio
lumbar nerve n of pain.
endings  Acknowle
secondary to
enlargement of ng dged the
pain
experienc
prov
the out pouching
abdominal aortic
aneurysm inter e and
convey
acceptan
ide
venti ce of
client’s
response
clue
ons, s
to pain.
 Monitore
d v/s
every

the 
4hrs.
Review
client’s
abou
patie previous
experienc
es with
t
nt pain and
methods
found in
diag
will nosi
the past.
 Teach
client and
significan

be t other
about the
non-
s,
able pharmac
ologic
ways to
and
to lessen
the pain. be
exper used
ience to
gradu .
dete
al rmin
reduc e
tion / treat
relief men
of t
pain requ
from ired
a -
pain Pain
scale is
of 8 subj
to at ectiv
least e
4. expe
After 8 hours of
nursing
interventions, rien
the patient will
be able to
experience ce
gradual
reduction /
relief of pain and
from a pain
scale of 8 to at
least 4. cann
.
ot
be
felt
by
othe
rs.
 Pain
asses
sment
can
provid
e
clues
about
diagno
sis,
and be
used
to
deter
mine
treatm
ent
requir
ed
 Pain is
 subjec
tive
experi
ence
and
cannot
be felt
by
others.
 Slight
increa
se of
RR
could
be
resulte
d from
the
possib
ility of
patient
’s
reactio
n
toward
s pain.
 May
be
helpful
for
manag
ement
pain
control
.
 To
 maxim
ize
opport
unities
for
self-
control
over
pain
manife
station
s

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTIO RATIONALE EVALUATIO

 N N
SUBJECTIVE: Acute pain may Hemorrhoids Independent: After 8 hours
“Masakit at
nahihirapan ako
be related to
inflammation and
are vascular
masses that After • Encourage
patient to Pain of nursing
interventions,
dumumi” (I've edema of protrude into report pain. the patient
been having
trouble/pain
prolapsed
varices.
the lumen of
the lower 8 • Assess
reports of asse was able to
report pain
pooping) as rectum or abdominal was relieved
verbalized by the
patient.
perianal area.
They result hours cramping or
pain, noting ssm or controlled.

OBJECTIVE: when location,

 Guarding
behavior
increased
intraabdominal of duration,
intensity (0-10 ent
pressure scale).
 Restlessne
ss
causes
engorgement in nursi Investigate and
report changes can
the vascular in pain
 Facial
mask of
pain
tissue lining the
anal canal. ng characteristics.
• Note prov
Loosening of nonverbal cues
 V/S taken
as follows:
vessels from
surrounding inter such as
restlessness, ide
connective reluctance to
P: 90
R: 20
T: 37.2
tissue occurs
with protrusion venti move and
abdominal clue
or prolapse into guarding.
BP: 120/80
the anal canal.
There are two ons, • Review
factors that s
types of aggravate or
hemorrhoids:
external the alleviate pain.
• Encourage abou
hemorrhoids patient to
appear outside assume
the external position of
sphincter, and
internal patie comfort.
• Provide t
hemorrhoids comfort
appear above
the internal nt measures.
• Cleanse diag
sphincter. rectal area with
When blood
within the will mild soap and
water or wipes nosi
hemorrhoids after each stool
becomes
clotted be and provide
skin care. s,
because of • Provide sitz
obstruction, the
hemorrhoids able bath as
appropriate. and
are referred to
as being
thrombosed. to Collaborative:
• Implement be
prescribed
exper dietary
modifications. used
.
ience to
gradu dete
al rmin
reduc e
tion / treat
relief men
of t
pain requ
from ired
a -
pain Pain
scale is
of 8 subj
to at ectiv
least e
4. expe
After 8 hours of
nursing
interventions, rien
the patient will
report pain is
relieved or ce
controlled..
and
cann
ot
be
felt
by
othe
rs.
May try to
tolerate
rather than
request
analgesics.
• Changes in
pain
characteristi
cs may
indicate
spread of
disease or
developing
complication
s.
• Body
language/no
nver bal
cues may be
both
physiological
and
psychologica
l and may be
used in
conjunction
with verbal
cues to
determine
the extent or
severity of
the problem.
• May
 pinpoint
precipitating
or
aggravating
factors such
as stressful
events, food
intolerance
or to identify
developing
complication
s.
• Reduces
abdominal

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTIO RATIONALE EVALUATIO

N N
SUBJECTIVE: Impaired skin Aedes Aegypti Independent After 3 days

“Nagkapasa-
integrity r/t
changes in the Dengue Virus After  Vital
signs
Pain of nursing
intervention,
pasa ako na barrier function Type I the goal is
maliliit,” as of the skin (Chikungunya monitore met through
d and
verbalized. Virus) recorded. demonstratio

OBJECTIVE:
IgG adheres to
the platelet 8  Instructe
d proper
asse n of proper
skin hygiene
(initiates and
marks
petechial rash on
of destruction of
the platelet) hours hygiene
and self-
care as
ssm compliance
with
the extremity treatment
non pitting
bipedal edema
thrombocytope
nia (50,000/mm of well in
her
surroundi
ent and
medication.
3 or less)
nursi can
ngs.
V/S taken as
follows: increased Dependent
T = 36.7 °C potential for
P = 70 bpm
R = 15 cpm
hemorrhage
stimulates ng  Admi prov
BP = 120/80 intense
inter ide
niste
mmHg inflammatory red
response pres
cribe
petechial rash,
high fever, venti d
med
s
clue
headache
ons, such
as
asco
s
the abou
rbic
acid
and

patie t
furos
emid
e..

nt diag
will nosi
be s,
able and
to be
exper used
ience to
gradu dete
al rmin
reduc e
tion / treat
relief men
of t
pain requ
from ired
a -
pain Pain
scale is
of 8 subj
to at ectiv
least e
4. expe
Short Term
Goal
rien
After 3 days of
nursing
intervention, ce
proper skin
hygiene and
maintenance of and
skin integrity is
demonstrated
cann
ot
be
felt
by
othe
rs.
Changes in
vitals signs
may indicate
infection.
Proper
hygiene will
prevent
infection and
complication.
A clean
environment
occurrence
of any
disease.
Vitamin C
promotes
wound
healing and
diuretics
decreases
renal
vascular
resistance
and may
increase
renal blood
flow.
 NURSING CARE PLAN
1. Dizziness
ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTIO RATIONALE EVALUATIO
N N
Subjectve: Risk for prone High blood  After8hours of
After Pain
Assist the
“maul ulaw ak behaviour pressure(HBP)or patient in nursing
daduma” as related to lack of hypertension identifying interventions,
verbalized by the knowledge about means high the patient was
8 asse
modifiabl
Patient. the disease. pressure(tension) e risk able to
in the arteries. factors verbalize
Objective: Arteries are like diet understanding
V/S taken as
follows:
vessels that carry
blood from the hours high in
sodium,
saturated
ssm of the disease
process and
BP- 1080/100 pumping heart to treatment
mmhg RR- 22
PR- 78
all the tissues
and organs of the of fats and
cholestero
l.
ent regimen

T- 36.2 body. High

blood pressure
does not mean nursi  Reinforce
the
can
excessive
motional tension,
although ng importanc
e of
adhering
prov
emotional
to
tension and
treatment
stress can
inter ide
regimen
temporarily and
increase blood keeping
pressure. Normal follow up
blood pressure is
below venti appointm
ents. clue
120/80;blood
pressure between
120/80and139/8 ons,  Suggest
frequent
position
s
9 is called"
prehypertension"
the changes,
leg
exercises
abou
patie when
lying
down.
t
nt  Encourage
patient to
diag
will decrease
or
eliminate
nosi
be caffeine
like in tea,
coffee,
s,
able cola and
chocolate
s.
and
to be
exper used
ience to
gradu dete
al rmin
reduc e
tion / treat
relief men
of t
pain requ
from ired
a -
pain Pain
scale is
of 8 subj
to at ectiv
least e
4. expe
rien
After8hoursof
nursing
interventions

ce
,the patient will
verbalize
understanding of
the
process
treatment
disease
and and
regimen
cann
ot
be
felt
by
othe
rs.
 These
risk
factors
have
been
shown
to
contrib
ute to
hypert
ension
 Lack of
cooper
ation is
commo
n
reason
for
failure
of
antihyp
ertensi
 ve
therap
y
 Decrea
ses
periph
eral
venous
pooling
that
may be
potenti
ated by
vasodil
ators.
 Caffein
e is a
cardiac
stimula
nt and
may
advers
ely
affect
cardiac
functio
n.

NURSING CARE PLAN

2. Headache
ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTIO RATIONALE EVALUATIO
N N
Subjective: Ineffective Due to the  Assess After 8 hours
“Sumakit Sakit
toy ulok ti duwa
individual coping
r/t situations of
sudden fall of
the patient it After for
referred
pain, as
Pain the patient
states that
aldawen” as crisis, personal may cause a the headache
verbalized by the
patient.
vulnerability, not
adequate
minor trauma
to the patients 8 appropria
te. asse is no more to
be felt.
support systems, head.
Objective:
BP- 1080/100
work overload,
inadequate hours  Note
when
pain
ssm
RR- 22 relaxation,
of ent
occurs.
PR- 78 severe pain, -Instruct
T- 36.2 excessive threat in and
to himself.
nursi can
encourag
e use of
relaxation
technique

ng such as
breathing
, imaging,
prov
inter and
listening
to music
ide
venti  Provide
comfort
clue
ons, s
measure.

 Notes
clients

the attitude
towards
pain and
abou
patie use of
pain
medicatio
t
 n

nt including
any
history of
diag
will substanc
e abuse. nosi
be s,
able and
to be
exper used
ience to
gradu dete
al rmin
reduc e
tion / treat
relief men
of t
pain requ
from ired
a -
pain Pain
scale is
of 8 subj
to at ectiv
least e
4. expe
After 8 hours
the patient
states that the rien
headache is no
more to be felt.
ce
and
cann
ot
be
felt
by
othe
rs.
 To
help
deter
mine
 possib
ility of
underl
ying
conditi
on or
organ
dysfun
ction
requiri
ng
treatm
ent.
 To
medic
ate
prophy
lactical
ly, as
appro
priate.
 To
distrac
t
attenti
on and
reduce
tensio
n
 To
promo
te non
pharm
acolog
ic pain
manag
 ement

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTIO RATIONALE EVALUATIO

N N
Subjective: Infection r/t Risk for Independent: After 8 hours
“Ang kati-kati po
ng pwerta ko.”
bacterial
invasion as
fetal/maternal
infection After 1.Avoid soap Pain the patient
states that
As verbalized by manifested by transmission and just rinse the headache
the patient vaginal itching related to
colonization of 8 with water to
clean asse is no more to
be felt.
Objective: pathogenic
(+) Restless
(+) Discomfort
organism.
hours 2. Avoid
douching. ssm
Looks anxious
Afebrile
V/S: of 3.Allow more
air to reach the ent
BP 110/70 PR genital area
64 bpm
RR 12 cpm nursi -Wear clean, can
 preferably
ng white, cotton
underwear. prov
inter -Wearing
loose-fitting ide
clothes and not
venti wearing panty
hose clue
-Not wearing
ons, underwear at
night when s
sleeping.
the 4.Maintain abou
good hygiene
patie - keep the t
vulva clean and
nt dry
diag
- external
will genitals should
be cleaned at nosi
least once
be each day
s,
Dependent:
able 1.Provide and
optimal relief
to with doctor’s
prescription. be
exper - application of
a topical yeast used
infection cream
ience - topical to
anesthetic
gradu creams or
sprays often dete
contains
al benzocaine
rmin
reduc e
tion / treat
relief men
of t
pain requ
from ired
a -
pain Pain
scale is
of 8 subj
to at ectiv
least e
4. expe
Short term
Goal: After 8
hours of rien
nursing
intervention,
the patient will ce
manifest signs
of minimized
itching, and and
discomfort
Long term
Goal: After 8 cann
hours of
nursing
intervention, ot
the patient will
be
knowledgable be
about proper
perineal
hygiene. felt
by
othe
rs.
-Can irritate
the delicate
tissue of the
external
vagina and
vulva

- it removes
healthy
bacteria that
line the
vagina.
These
bacteria help
protect
against
infection.
-Cotton
increases air
flow and
decreases
moisture
build up.

-Moisture
enhances
growth of the
microorganis
ms which
cause
external
vaginal
itching

-can trap or
increase
perspiration
and set up
an
environment
for
vaginal/vulva
l irritations.

- It is
essential to
determine
the cause of
itching with a
practitioner
 before using
any
medicine. -
soothe
itching by
numbing the
skin where
they are
applied

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTIO RATIONALE EVALUATIO

N N
SUBJECTIVE: Health seeking Inadequate INDEPENDEN After two

The client stated

behavior related
to guidelines for
comprehension
; low self- After T:
Pain hours of
nursing
that she is nutrition and efficacy Assess level of intervention
worried about
the upcoming
activity during
pregnancy Negative 8 anxiety through
verbal and asse the the client
was able to
delivery of the perception of nonverbal manage the
baby due to her
anxiety and
healthcare
provider or hours cues.
ssm client’s
anxiety with
because it will be recommended Employ a calm, positive
her first
pregnancy.
healthcare
strategy. of caring,
confident, and ent coping
mechanisms
non-judgmental as evidenced
OBJECTIVE:
nursi approach.
can by:

 The patient Recognize The client

exhibits normalcy of was able to
 poor eye fear and give verbalize
contact
upon
interaction.
ng chance to
questions and prov desire to
participate
answer and follow
 The patient
has an
inter genuinely
within the pt. ide appropriate
instructions
degree of during her
evident
grimacing
and facial
venti comprehension
. clue entire course
of labor.
Dependent:
ons, s
tension.
The client
 The client Administer was able to
antianxiety manifest a
the abou
has a hard
time medication as positive
focusing ordered by the attitudeand
and giving physician. outlook


attention.

The client
patie Implement t towards
healthcare
relaxation personhealth
appears
distracted
and
nt techniques or
distractions as diag care
personnel
instructed by and support
preoccupie
d. will the physician
nosi group or
people.
Collaborative:
be Refer to s, The client
expressed
support groups confidence
able as necessary.
and and trust in
herself, her
support
to be group, and
the
 healthcare
exper used workforce.

The client
ience to acquired
sufficient
knowledge
gradu dete about
childbirth and
is better
al rmin arranged to
adapt to
future births.
reduc e
tion / treat
relief men
of t
pain requ
from ired
a -
pain Pain
scale is
of 8 subj
to at ectiv
least e
4. expe
GOAL:
This nursing
care plan aims rien
to manage the
client’s anxiety
with positive ce
coping
mechanisms
after 2 hours. and
OUTCOME
CRITERIA: cann
The client will
verbalize ot
desire to
participate and
follow be
appropriate
instructions
during her felt
entire course of
labor.
by
The client will
manifest
positive
a
othe
attitudeand
outlook
towards rs.
healthcare Identify
personnel and areas of
support group concern that
or people. might
interfere with
The client will the normal
express progress of
confidence and labor.
trust in herself,
her support Enhances
group, and the nurseclient
healthcare relationship.
workforce. Adequate
clarification
The client will lessens
acquire uneasiness,
sufficient relieve fears,
knowledge and gives
about childbirth confirmation.
and is better
arranged to Mechanism
adapt to future of action is
births. to diminish
nervousness
and relieveu
anxiety.

Helps in
decreasing
stress/nervo
usness and
provides a
sense of
control over
the situation

Provides
ongoing and
timely
support.
 NURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTIO RATIONALE EVALUATIO

N N
Subjective: Exchange Entry of Independent: Discharge
“Mabilis ang
kanyang
related to altered
oxygen supply
noxious
particles or After -Monitor skin Pain Outcome

paghinga” as (obstruction of gases to the and mucous ACHIEVED:

stated. airways by
secretion) as
lungs
↓ 8 membrane
color asse After 3 days
Objective: evidenced by Release of of nursing
-RR: 28 cpm wheezes upon mediators -Elevate head intervention
-PR: 102 bpm
-wheezes upon
auscultation. ↓
Abnormal hours of the bed,
assist patient to ssm the client:

auscultation inflammation of assume -Manifested

-with pulse
oxymeter -with
the lungs
↓ of position to
ease work of ent absence of
wheezes
mechanical Chronic breathing upon
ventilator inflammation
↓ nursi -Suction when can auscultation

Scar tissue needed - Attained

formation
↓ ng -Auscultate prov normal
breathing
Narrowing of breath sounds, pattern of 20
airway lumen
↓ inter noting areas of
decreased air- ide cpm Short

Airflow flow or -term

limitations
↓ venti presence of
adventitious clue outcome

Impaired gas sound -Palpate ACHIEVED:

exchange
↓ ons, for fremitus.
s After 2 hours
of nursing
wheezes -Provide quiet intervention
the environment to
allow the abou the client:
-
patient to relax Demonstrate
patie Collaborative: t d improved
ventilation
and
nt -Monitor pulse
oximetry and diag adequate
oxygenation
ABGs of tissues by
will -Administer nosi ABG of:
pH:7.35-7.45
 antianxiety, paCO2: 35-
be sedative, or
narcotic agents s, 45mmHg
paO2: 80-
as 95mmHg
able indicated(e.g.m
orhine ) and -decreased
respiratory
rate from
to -Hooked to
mechanical be 28cpm to 13
cpm
ventilator
exper used
ience to
gradu dete
al rmin
reduc e
tion / treat
relief men
of t
pain requ
from ired
a -
pain Pain
scale is
of 8 subj
to at ectiv
least e
4. expe
Discharge
Outcome:
After 3 days of rien
nursing
intervention the
client: ce
-Manifest
absence of and
wheezes upon
auscultation
cann
-Attain normal
breathing
pattern of 20 ot
cpm Short

-term outcome: be
After 2 hours of
nursing felt
intervention the
client:
by
-Demonstrate
improved
ventilation and othe
adequate
oxygenation of
tissues by ABG rs.
of: -Duskiness
pH:7.35-7.45 and central
paCO2: 35- cyanosis
45mmHg indicate
paO2: 80- advanced
95mmHg hypoxemia

-Decrease -Oxygen
respiratory rate delivery may
from 28cpm to be improved
13 cpm by upright
suctioning

-Suctioning
is required
when cough
is ineffective
for
expectoratio
n of
secretions

-Presence of
wheezes
may indicate
bronchospas
m/ retained
secretions

-Decrease of
vibratory
tremors
suggest fluid
collection or
air tapping
External
stimuli may
prevent
relaxation or
inhibit sleep

-to identify if
hypoxia is
present

-to reduce
dyspnea by
controlling
the anxiety
and
restlessness

-use as aid
in treatment