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 Sputum culture  Assist with and sensitivity activities of help identify daily living as causative tolerated. organism and guide appropriate antibiotic therapy.  To conserve energy and  Provide comfort promote measures as comfort. needed.  Comfort measures help alleviate dyspnea and anxiety. Collaborative:  To provide the  Consult best plan of physician if care. condition worsens or does not improve as expected.

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62 views3 pages

NCP Scribd

 Sputum culture  Assist with and sensitivity activities of help identify daily living as causative tolerated. organism and guide appropriate antibiotic therapy.  To conserve energy and  Provide comfort promote measures as comfort. needed.  Comfort measures help alleviate dyspnea and anxiety. Collaborative:  To provide the  Consult best plan of physician if care. condition worsens or does not improve as expected.

Uploaded by

Angela Ayala
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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NURSING CARE PLAN

Cues Nursing Diagnosis Rationale Nursing Nursing Rationale Expected


Subjective/Objective Objectives interventions Outcome
(Evaluation)
Subjective: Ineffective An ineffective Short term: Independent: Goal Met
Patient verbalized breathing pattern breathing pattern is After 4 hours of
“Nahihirapan ako related to acute defined as nursing  Monitor  Respiratory After the
huminga” infection and inspiration and/or intervention, respiratory status intervention the
“Hindi na ako decreased lung expiration that patient will deny status, assessment patient maintains
makatayo ng maayos capacity. does not provide shortness of breath. including vital help gauge the an effective
sa sobrang sakit” adequate signs and skin patient’s breathing pattern,
oxygenation. This Long term: color. severity and as evidenced by
Objective: diagnosis is related After 1 day of whether it’s relaxed breathing
 RR: 41 bpm to the observed rate nursing progressing. at normal rate
 Crackles and depth of intervention the and depth and
 Dyspnea breathing, as well patient will  Assess and  It’s important absence of
 Pale in as abnormal chest promote good record to take action dyspnea.
appearance expansion, and respiratory respiratory rate when there is
 Productive accessory muscle function, treat and depth at an alteration in Patient reports
cough use that results in a infection and least every 4 breathing feeling rested
breathing pattern promote comfort. hours. patterns to each day.
that does not detect early
supply adequate signs of
ventilation to the compromise on
body. the respiratory
system

 Unusual
 Observe breathing
breathing patterns may
patterns imply an
underlying
disease process
or dysfunction.

 This to detect
decreased or
 Auscultate adventitious
breath sounds breath sounds.
at least every 4
hours.

 Work of
breathing
 Assess for the increases
use of greatly as lung
accessory compliance
muscle. decrease.

 To increase
chest
 Place the expansion and
patient in to alleviate
semi-fowlers dyspnea.
position and
place the
diaphragm in
proper position
to contract.

Dependent:
 To provide
 Administer relief from
oxygen symptoms of
therapy as hypoxemia and
ordered. hypoxia.

 ABG labels
 Monitor ABG and continuous
levels and pulse oximetry
oxygen measures the
saturation as blood’s oxygen
ordered. content and are
good indicator
of the lung’s
ability to
oxygenate the
blood.
 To monitor the
 Collect sputum progress of the
samples as disease and
ordered. treatment.

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