NURSING CARE PLAN

PATIENT’S NAME: AGE: 7 years old

DIAGNOSIS: Congenital Heart Disease Double Outlet Right ventricle with Pulmonary Stenosis

NURSING
ASSESSMENT INFERENCE GOAL INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
INDEPENDENT:
OBJECTIVE: Ineffective Due to SHORT-TERM:  Affecting systemic SHORT-TERM:
 Cyanotic tissue decreased After 8 hours of nursing  Note current situation circulation/perfusio GOAL FULLY MET
lips perfusion r/t cardiac output, interventions, or presence of n After 8 hours of nursing
 Pale decreased there is patient(guided by the conditions that can  To identify client at interventions, patient was
conjunctiva cardiac decreased mother) will be able to affect perfusion to all higher risk for able to demonstrate
and nail output preload and demonstrate behaviors to body systems(CHD venous stasis, behaviors to improve
beds stroke volume improve circulation, as DORV with PS) vessel wall injury circulation, as evidence
 Weak thus there is evidence by:  Identify presence of and by:
peripheral decreased  Engage foot-ankle high risk hypercoagulability..  Engage foot-ankle
pulses blood pumped exercises factors(problem in  To determine exercises
 Cold out from the  Use of pressure coronary circulation) adequacy of  Use of pressure
clammy skin blood. relieving  Measure capillary refill systemic circulation relieving
 Dry, scaly Decrease in devices(foam  Inspect lower  That often devices(foam
skin stroke volume padding) extremities for skin accompany padding)
 Decreased decreases  Changes position at texture(lack of hair, dry diminished  Changes position
skin turgor perfusion timed intervals and scaly) peripheral at timed intervals
>4 seconds throughout the circulation
 Decrease body.
capillary
refill 4
seconds
LONG-TERM: LONG-TERM:
After 2 days of nursing DEPENDENT PARTIALLY MET
interventions, patient will  To promote optimal After 2 days of nursing
be able to demonstrate  Administer KCL and interventions, patient was
  ABG(respira increased perfusion, as Ferrous Sulfate blood flow, organ able to demonstrate
tory evidence by: prefusion, and increased perfusion, as
alkalosis)  Warm skin COLLABORATIVE: function evidence by:
 Moist, smooth skin  Warm skin
 Collaborate in 
 Peripheral pulses To maximize  Peripheral pulses
 CBC(Decre treatment of underlying systemic circulation
present and strong present and strong
conditions(cardiopulmo
ase  Normal skin turgor and organ  Normal skin turgor
nary conditions)
hemoglobin + 2 seconds perfusion  Normal capillary
 Refer to dietician
and  Normal capillary refill <2
hematocrit) refill <2 seconds  For well-balanced, seconds(not met)
 Normal ABG result low saturated-fat,  Normal ABG
 CBC(Hemoglobin low cholesterol diet result(not met)
and hematocrit and other  CBC(Hemoglobin
within normal limits) modifications as and hematocrit
indicated. within normal
limits)

NURSING CARE PLAN

PATIENT’S NAME: AGE: DIAGNOSIS: cough and
colds
NURSING
ASSESSMENT INFERENCE GOAL INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE LONG TERM INDEPENDENT LONG TERM
 “Hirap siyang Ineffective airway Irritant After 3 days of  Monitor  It is an indication After 3 days of
makahinga” as clearance related nursing intervention, respiratory of respiratory nursing interventions,
verbalized by to retained (inhalation) the client will have rate distress and the goal has been
the mother secretions effective airway accumulation of fully met as
clearance as secretions manifested by:
OBJECTIVE inflammatory manifested by:  Absence of
 Pale in crackles
appearance response EXPECTED  Position in a  To open or  Absence of
 Presence of OUTCOME semi-fowler’s maintain airway secretions
clear nasal  clear breath position and it also  Having an
discharge sounds enhances effective
increase  clear
 Presence of drainage to airway
production secretions different lung clearance.
crackles on the
bilateral lung  good airway segments  Good airway
of secretions
field patency patency
 Ineffective
SHORT TERM  Keep  Physical or SHORT TERM
 coughing Accumulation of After 3 hours of environment chemical After 3 hours of
 RR= 32 secretions nursing intervention, allergen free allergen serves nursing intervention,
 restlessness the patient will be able such as as irritants the short term goal
cleaning to
to expectorate was fully met as
Blocks the airway remove dusts.
(airway secretions as evidenced by:
constriction) evidenced by:  Increase fluid  Hydration can
 Effective
intake help liquefy
coughing
viscous
clearing the
secretion and
changes in the retained
improve
respiratory pattern secretions
secretion
clearance
EXPECTED  Enhanced
 Monitor for  It may
dyspnea OUTCOME: airway
feeding compromise
patency
intolerance, airway
work of breathing  Effective abdominal
increases to coughing and  Normal
distention and
compensate for the clearing of respiratory
emotional
blockage. retained rate
stressors.
secretions
 Auscultate  To ascertain
breath sounds status and note
 Enhanced
and assess air progress
airway
movement
patency
REFERENCE/S  Give chest  To remove
Medical Surgical  Normal physiotherapy bronchial
Nursing, 11th respiratory secretions and
Edition by improve
Smeltzer and Bare, ventilation
 Encourage
page 602
deep breathing
exercises  To promote
proper lung
DEPENDENT expansion
 Administer
salbutamol
neb as  Act as a
ordered bronchodilator
REFERENCE/S
Medical Surgical
Nursing, 11th Edition by
Smeltzer and Bare,
page 731.