POLYTECHNIC COLLEGE OF DAVAO DEL SUR, INC.

MacArthur Highway, Digos City

NURSING CARE PLAN
Name of Patient: Casas__________________________________
Age: 53 yrs old Sex: Male__Civil Status: Married_____________
Occupation: laborer Religion: Roman Catholic_____________
Address: _______________________________________________
Ward: Medicine Ward Room No.: #33 Non-infectious_Bed No.#4_
Attending Physician:Dr. Maria Lourdes G. Pasaporte-Alisasis______________
Diagnosis: Community Acquired Pneumonia - Moderate Risk______________
_______________________________________________________________
Chief Complaint: dyspnea, cough____________________________________
Date of Admission: January 5, 2018___________________________________

Date/Time Cues Need Nursing Scientific Basis Goals Objectives Nursing Interventions Rationale Evaluation
s Diagnosis Criteria

Jan. 11, Subj: A Ineffective Within 8 hours of 1. Monitor VS. 1. To obtain baseline data GOAL MET
2018 “Ginapunga gyapon C airway nursing intervention, 2. Assess mentation for 2. Restlessness,
Within 8 hours of
@ sya og ginaubo,” as T clearance SOURCE: Med- patient will be able to signs of hypoxia. inappropriateness
8AM verbalized by I Related to Surg Lippincott maintain airway 3. Assess capillary refill should be watched out nursing intervention,
patient’s SO. V Excessive Williams patency as evidenced time. for patient was able to
I mucus &Wilkins page by: 4. Assess RR and pattern. 3. To determine adequate maintain airway
patency as evidenced
Obj: T Secondary 5th edition  VS within normal 5. Auscultate lung sounds oxygenation
Y to and note presence of 4. To provide information by:
limits
 With patent and  VS of
- Community  Absence of crackles or wheezes about effective
intact NGT noted E Acquired 6. Maintain on moderate breathing pattern T: 36.7 C
complications
 Productive cough X Pneumonia such as hypoxia, high back rest position. 5. Reveals presence of PR: 77 bpm
noted with E – Moderate 7. Promote restful and pulmonary congestion/ RR: 21 cpm
cyanosis, severe
yellowish phlegm R Risk quiet environment collection of secretion, BP: 130/80mmHg
dyspnea
 Dysphagia noted  Absence of
C  Demonstrate 8. Keep back dry indicating need for
 Use of accessory I behaviors to 9. Suction airway PRN as further intervention complications
muscles noted S ordered 6. To allow lung expansion such as hypoxia,
improve airway
 Dyspnea noted E such as coughing 10. Encourage deep 7. To promote rest cyanosis, severe
 Orthopnea noted exercises, breathing and coughing 8. To lessen mucus dyspnea
 Crackles noted P backtapping exercises production  Demonstrate
upon auscultation A 11. Administer 9. To remove secretions behaviors to
 Difficulty T expectorants/bronchodil 10. To maximize effort to improve airway
vocalizing noted T ators as ordered. expel secretions such as coughing
 Restlessness E 11. To improve airway exercises,
noted R backtapping
N
 POLYTECHNIC COLLEGE OF DAVAO DEL SUR, INC.
MacArthur Highway, Digos City
NURSING CARE PLAN
Name of Patient: Galarian, Rolando __________ Attending Physician: Dr. Alisasis____________________________________
Age: 57 yrs old Sex:Male___Civil Status: Married________________ Diagnosis: Urinary Tract Infection to consider Kidney Stones_______________
Occupation: laborer Religion: Roman Catholic______________ _________URO Spinal Cord Injury____________________________________
Address: Kiblawa, Davao del Sur Chief Complaint: lower extremity weakness, dysuria______________________
Ward: Medicine Ward Room No.: #38 A Infectious Bed No.#6_____ Date of Admission: Jan. 11, 2018_____________________________
Date and Cues Need Nursing Scientific Basis Objective Nursing Intervention Rationale Evaluation
Time Diagnosis
August 3, S: A Activity the reduction in Within 8 hours of 1. Monitor vital signs. 1. For baseline data Goal Met
2017 “Galuya gyapon C Intolerance tissue oxygen nursing 2. Encourage patient to 2. Informing about
@ akong paa di ko T related to decreases the intervention, the verbalize feelings and condition and limitations Within 8 hours of nursing
8AM gusto sigeg I lower reduction of ATP, patient will be able concerns regarding prevents to develop intervention, the patient was
lihok”, as V extremities the immediate to report present condition and further complication and able to report measurable
verbalized by pt. I weakness energy source for measurable limitations. it will be a help to increase in activity tolerance as
T muscle increase in activity 3. Maintain stressful manage properly evidenced by:
O: Y contraction. In tolerance as activity restrictions and condition.
 With - addition, the evidenced by: assist patient with self 3. Reduces physical stress Reduced feeling of fatigue and
weakness on E impaired care activities as and tension, it decreases weakness
lower legs X circulation causes Reduced feeling of needed. the demand of oxygen
noted E a decrease in the fatigue and 4. Encourage rest periods 4. To reduce fatigue Able to mention and apply ways
 Weak in R removal of the weakness between care activities. 5. To prevent overexertion on how to manage condition
appearance C metabolic waste 5. Encourage 6. To prevent injury
noted I product, the result Able to mention PROM/AROM. Participated to interventions
 Pallor noted S of these is further and apply ways on 6. Maintain safety
 Shortness of E decreased muscle how to manage measures.
breath noted function condition
 Needs P
assistance in A Med-Surg 3rd Participate to
doing T edition by Phillips interventions
minimal T p.678
activities E
noted R
 Easy N
fatigability
 POLYTECHNIC COLLEGE OF DAVAO DEL SUR
MacArthur Highway, Digos City

Requirements on
RLE 107B – Head Nursing (Related Learning Experience)

A Requirement Presented to

Sir Jay Pee Malibiran, RN

Clinical Instructor

Submitted by:

Mary Shan Padilla

BSN 4

January 2018