Nursing care plan

Patient: Gladys Santos Age: 31 years old CC: cough

ASSESSMENT DIAGNOSIS RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Short term: Independent: Short term:

“kulang na din P After 4-8 hours Assess airway for Maintaining the After 7 hours of
ako sa tulog kasi Ineffective of nursing patency. airway is always nursing
masakit ang airway intervention, the the first priority, intervention, the
lalamunan ko at clearance patient will be especially in patient was able
dibdib kapag able to: cases of trauma, to:
umuubo ako Related to >sustain a acute >sustained a
kaya naiistorbo respiratory neurological respiratory
ang tulog ko E copious rate between decompensation, rate between
tapos tracheo- 23-27 or cardiac arrest. 23-27 breaths
nagpaconfine pa bronchial breaths per per minute
ako. Nahihirapan secretions minute Assess cough for Consider
din akong effectiveness and possible causes >expressed
huminga lalo na As >express productivity. for ineffective ease on
kapag nakahiga manifested ease on cough (e.g., breathing
ako”, as by breathing respiratory
verbalized by the muscle fatigue, >Allayed
patient S >Allay severe restless-ness.
“kulang na restless-ness. bronchospasm, or
din ako sa thick tenacious
Objective: tulog kasi secretions).
>cough masakit ang Assess patient’s Patient education “Goal met”
>Tachypnea. lalamunan knowledge of will vary
RR of 38 ko at dibdib disease process. depending on the
>Patient prefers kapag acute or chronic
high fowler’s umuubo ako disease state as LONG TERM:
position so she kaya LONG TERM: well as the After 3 days of
can breathe naiistorbo After 2-4 days patient’s nursing care, the
better. ang tulog ko of nursing care, cognitive level patient was able
>Dull thud at tapos the patient will These improve to:
upon percusiion. nagpaconfin be able to: productivity of > have
>Crackles are e pa ako. > have the cough. respiration
present at right Nahihirapan respiration rate between
and left lungs. din akong rate between Assist patient in Directed 18-25 breaths
>Rhonchi are huminga 18-25 performing coughing per min
heard over the lalo na breaths per coughing and techniques help
large airways. kapag min breathing mobilize >expectorate
>Patient shows nakahiga maneuvers. secretions from secretions
increased ako”, as >expectorate Instruct patient in smaller airways effectively
workload of verbalized secretions the following: to larger airways
breathing. by the effectively because the >have Normal
patient, >Optimal coughing is done chest x-ray
cough, > Normal positioning (sitting at varying times. results
Tachypnea, chest x-ray position) The sitting
RR of 38, results position and >Allay restless-
Patient >Use of pillow or splinting the ness
prefers high >Allay restless- hand splints when abdomen promote >verbalized
fowler’s ness coughing more effective improved activity
position, >verbalized coughing by tolerance.
Dull thud at improved increasing
>Use of abdominal
upon activity abdominal “Goal met”
muscles for more
percusiion, tolerance. pressure and
forceful cough
Crackles upward
present at >Use of quad and diaphragmatic
right and movement.
left lungs,
Rhonchi are huff techniques
heard over
the large >Use of incentive
airways, spirometry
Patient
shows >Importance of
increased ambulation and
workload of frequent position
breathing changes
These promote
Use positioning (if better lung
tolerated, head of expansion and
bed at 45 degrees; improved air
sitting in chair, exchange.
ambulation).
This loosens
Use humidity secretions.
(humidified oxygen
or humidifier at
bedside).
Increased fluid
Encourage oral intake reduces
intake of fluids the viscosity of
within the limits of mucus produced
cardiac reserve. by the goblet cells
in the airways. It
is easier for the
patient to
mobilize thinner
secretions with
 coughing.

Fatigue is a
pace activities. contributing
Maintain planned factor to
rest periods. ineffective
Promote energy- coughing.
conservation
techniques.
Patient will
Demonstrate and understand the
teach coughing, rationale and
deep breathing, and appropriate
splinting techniques to
techniques. keep the airway
clear of
secretions.

Smoking
Explain effects of contributes to
smoking, including bronchospasm
second-hand and increased
smoke. mucus production
in the airways.

To treat infection,
Dependent: liquefy secretions
Administer and let the patient
medications. be aware of the
Instruct patient on side effects.
indications for,
frequency, and side
effects of
medications. Chest
physiotherapy
Collaborative: includes the
Consult respiratory techniques of
therapist for chest postural drainage
physiotherapy and and chest
nebulizer percussion to
treatments as mobilize
indicated (hospital secretions in
and home smaller airways
care/rehabilitation that cannot be
environments). removed by
coughing or
suctioning.
Nursing care plan
Patient: Gladys Santos Age: 31 years old CC: cough

ASSESSMENT DIAGNOSIS RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Short term: Determine cause of

“wala naman P Activity After 5-8 hours activity intolerance
akong arthritis. Intolerance of nursing (see Related Factors)
Pakiramdam ko intervention, the and determine
ngayon ay Related to patient will: whether cause is
parang lagi >be willing to physical,
akong E impaired participate in psychological, or
nanghihina kaya respiratory activities related motivational.
matamlay ako. function, to her care Determining the
Kulang din ako anemia and cause of a problem
sa tulog.”, as dialysis >identify can help direct
verbalized by the procedure factors that can appropriate
patient. help increase interventions.
her activity
 EditIf mainly
As tolerance
on bed rest,
manifested
minimize
Objective: by >plan a
cardiovascular
>Reluctance to schedule of
deconditioning by
attempt S activities to
positioning the client
movement “wala preserve energy
in an upright position
>BP = 170/120 naman and utilize it
several times daily if
mmHg akong properly
possible.
>RR = 38 arthritis.
Deconditioning of
breaths per Pakiramdam >
the cardiovascular
minute ko ngayon
>Decreased ay parang system occurs within
muscle lagi akong days and involves
endurance, nanghihina fluid shifts, fluid
strength, control, kaya loss, decreased
or mass matamlay cardiac output,
>body weakness ako. Kulang decreased peak
>tired facial din ako sa oxygen uptake, and
expression tulog.”, as increased resting
verbalized heart rate (Fletcher,
by the 2005; Fauci et al,
patient, 2008). A study found
Reluctance that diabetic clients
to attempt developed
movement, orthostatic
BP = hypotension after 48
170/120 hours of bed rest,
mmHg, RR possibly from altered
= 38 breaths cardiovascular
per minute, reflexes (Schneider
Decreased et al, 2009).
muscle
 EditAssess
endurance,
the client daily for
strength,
appropriateness of
control, or
activity and bed rest
mass, body
orders. Mobilize the
weakness,
client as soon as it is
tired facial
possible. With bed
expression
rest there is a shift of
fluids from the
extremities to the
thoracic cavity from
the loss of
gravitational stress.
Positioning in an
upright position
helps maintain
optimal fluid
distribution and
maintain orthostatic
tolerance (Perme &
Chandrashekar,
2009). EB: A study
utilizing tomography
demonstrated
significant
decreased strength
in the hip, thigh, and
calf muscles in
elderly orthopedic
clients, as well as
bone mineral loss
with immobility
(Berg et al, 2007).
 EditIf client
is mostly immobile,
consider use of a
transfer chair: a chair
that becomes a
stretcher. Using a
transfer chair where
the client is pulled
onto a flat surface
and then seated
upright in the chair
can help previously
immobile clients get
out of bed (Nelson et
al, 2003; Perme &
Chandrashekar,
2009).
 EditWhen
appropriate,
gradually increase
activity, allowing the
client to assist with
positioning,
transferring, and
self-care as possible.
Progress from sitting
in bed to dangling, to
standing, to
ambulation. Always
have the client
dangle at the bedside
before trying
standing to evaluate
for postural
hypotension.
Postural
hypotension is very
common in the
elderly (Krecinic et
al, 2009).
 EditWhen
getting a client up,
observe for
symptoms of
intolerance such as
nausea, pallor,
dizziness, visual
dimming, and
impaired
consciousness, as
well as changes in
vital signs. When an
adult rises to the
standing position,
300 to 800 mL of
blood pools in the
lower extremities. As
a result, symptoms of
central nervous
system
hypoperfusion may
occur, including
feelings of weakness,
nausea, headache,
lightheadedness,
dizziness, blurred
vision, fatigue,
tremulousness,
palpitations, and
impaired cognition
(Bradley & Davis,
2003).
 EditIf the
client experiences
symptoms of
postural hypotension
as outlined above,
take precautions
when getting the
client out of bed. Put
graduated
compression
stockings on client or
use lower limb
compression
bandaging if ordered
to return blood to the
heart and brain. Have
the client dangle at
the side of the bed
with legs hanging
over the edge of the
bed, flex and extend
feet several times
after sitting up, then
stand up slowly with
someone holding the
client. If client
becomes light
headed or dizzy,
return them to bed
immediately.
Postural
hypotension is
common and can
occur with both
younger and older
clients from
immobility and
deconditioning. Use
of compression
stockings or leg
bandaging can help
return fluid from the
lower extremities
back where it
collects from
immobility to the
heart and brain
(Gorelik et al, 2009;
Platts et al, 2009).
 EditPerform
range-of-motion
(ROM) exercises if
the client is unable to
tolerate activity or is
mostly immobile.
See care plan for
Risk for Disuse
syndrome.
 EditMonitor
and record the
client's ability to
tolerate activity: note
pulse rate, blood
pressure, monitor
pattern, dyspnea, use
of accessory
muscles, and skin
color before, during
and after the activity.
If the following signs
and symptoms of
cardiac
decompensation
develop, activity
should be stopped
immediately:

• Onset of
chest
discomfort
• Dyspnea
• Palpitations
• Excessive
fatigue
• Lightheadedn
 ess,
confusion,
ataxia, pallor,
cyanosis,
nausea, or
any
peripheral
circulatory
insufficiency
• Dysrhythmia
• Exercise
hypotension
(drop in
systolic blood
pressure of
10 mm Hg
from baseline
blood
pressure
despite an
increase in
workload)
• Excessive
rise in blood
pressure
(systolic
>180 mm Hg
or diastolic
>110 mm
Hg) Note:
These are
 upper limits;
activity may
be stopped
before
reaching
these values
• Inappropriate
bradycardia
(drop in heart
rate >10
beats/min or
<50
beats/min)
• Increased
heart rate
above 100
beats/min

 EditInstruct
the client to stop the
activity immediately
and report to the
physician if the
client is experiencing
the following
symptoms: new or
worsened intensity
or increased
frequency of
discomfort; tightness
or pressure in chest,
back, neck, jaw,
shoulders, and/or
arms; palpitations;
dizziness; weakness;
unusual and extreme
fatigue; excessive air
hunger. These are
common symptoms
of angina and are
caused by a
temporary
insufficiency of
coronary blood
supply. Symptoms
typically last for
minutes as opposed
to momentary
twinges. If symptoms
last longer than 5 to
10 minutes, the
client should be
evaluated by a
physician. Pulse rate
and arterial blood
oxygenation indicate
cardiac/exercise
tolerance; pulse
oximetry identifies
hypoxia (Grimes,
2007; Schmitz,
2007).
 EditObserve
and document skin
integrity several
times a day. Activity
intolerance, if
resulting in
immobility, may lead
to pressure ulcers.
Mechanical
pressure, moisture,
friction, and
shearing forces all
predispose to their
development (Fauci
et al, 2008). Refer to
the care plan Risk
for impaired Skin
integrity.
 EditAssess
for constipation. If
present, refer to care
plan for
Constipation.
Activity intolerance
is associated with
increased risk of
constipation.
 EditRefer the
client to physical
therapy to help
increase activity
levels and strength.
 EditConsider
a dietitian referral to
assess nutritional
needs related to
activity intolerance,
provide nutrition as
needed. If client is
unable to eat food,
use enteral or
parenteral feedings
as needed.

EditRecognize that
malnutrition causes
significant morbidity
due to the loss of
lean body mass.
Providing nutrition
early helps maintain
muscle and immune
system function, and
reduce hospital
length of stay
(McClave et al,
2009; Racco, 2009).
 EditProvide
emotional support
and encouragement
to the client to
gradually increase
activity. Work with
the client to set
mutual goals that
increase activity
levels. Fear of
breathlessness, pain,
or falling may
decrease willingness
to increase activity.
 EditObserve
for pain before
activity. If possible,
treat pain before
activity and ensure
that the client is not
heavily sedated.
Pain restricts the
client from achieving
a maximal activity
level and is often
exacerbated by
movement.
 EditObtain
any necessary
assistive devices or
equipment needed
before ambulating
the client (e.g.,
walkers, canes,
crutches, portable
oxygen). Assistive
devices can help
increase mobility
(Yeom, Keller, &
Fleury, 2009).
 EditUse a
gait walking belt
when ambulating the
client. Gait belts
improve the
caregiver's grasp,
reducing the
incidence of injuries
(Nelson et al, 2003).

• EditIf the
client is able
to walk and
has chronic
obstructive
pulmonary
disease
 (COPD), use
the traditional
6minute walk
distance to
evaluate
ability to
walk. EB:
The 6minute
walk test
predicted
mortality in
COPD
clients
(Pinto-Plata
et al, 2004).
• EditEnsu
re that the
chronic
pulmonary
client has
oxygen
saturation
testing with
exercise. Use
supplemental
oxygen to
keep oxygen
saturation 90
or above or
 as prescribed
with activity.
Clients with
COPD may
suffer from
inadequate
gas
exchange.
Oxygen
therapy can
improve
exercise
ability and
ability to
think in
hypoxemic
clients (Celli,
MacNee, &
ATS/ERS
Task Force,
2004).
• EditMoni
tor a
respiratory
client's
response to
activity by
observing for
symptoms of
respiratory
 intolerance
such as
increased
dyspnea, loss
of ability to
control
breathing
rhythmically,
use of
accessory
muscles,
nasal flaring,
appearance of
facial
distress, and
skin tone
changes such
as pallor and
cyanosis
(Perme &
Chandrashek
ar, 2009).
• EditInstr
uct and assist
a COPD
client in
using
conscious,
controlled
breathing
techniques
during
exercise,
including
pursed-lip
breathing,
and
inspiratory
muscle use.
EBN: A
systematic
review found
pursed-lip
breathing
effective in
decreasing
dyspnea
(Carrieri-
Kohlman et
al, 2008).
EB: A
systematic
review found
that
inspiratory
muscle
training was
effective in
increasing
endurance of
the client and
 decreasing
dyspnea
(Langer et al,
2009).
• EditEval
uate the
client's
nutritional
status. Refer
to a dietitian
if needed.
Use
nutritional
supplements
to increase
nutritional
level if
needed.
Improved
nutrition may
help increase
inspiratory
muscle
function and
decrease
dyspnea.
EBN: A
study found
that almost
half of a
 group of
clients with
COPD were
malnourished
, which can
lead to an
exacerbation
of the disease
(Odencrants,
Ehnfors, &
Ehrenbert,
2008).
• EditFor
the client in
the intensive
care unit,
consider
mobilizing
the client in a
four-phase
method if
there is
sufficient
knowledgeab
le staff
available to
protect the
client from
harm. Even
intensive
 care unit
clients
receiving
mechanical
ventilation
can be
mobilized
safely if a
multidisciplin
ary team is
present to
support,
protect, and
monitor the
client for
intolerance
to activity
(Perme &
Chandrashek
ar, 2009).
• EditRefer
the COPD
client to a
pulmonary
rehabilitation
program.
EB: A
Cochrane
review found
that
pulmonary
rehabilitation
has been
shown to
relieve
dyspnea and
fatigue
(Lacasse et
al, 2006).
Another
Cochrane
review found
pulmonary
rehabilitation
effective to
decrease
mortality and
rate of
readmission
for the client
who was
recently
discharged
after
treatment for
an
exacerbation
of COPD
(Puhan et al,
2009).
ASSESSMENT DIAGNOSIS RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION
ASSESSMENT DIAGNOSIS RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION
ASSESSMENT DIAGNOSIS RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION
ASSESSMENT DIAGNOSIS RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION
ASSESSMENT DIAGNOSIS RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION
ASSESSMENT DIAGNOSIS RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION