NURSING CARE PLAN

ASSESSMENT NURSING PLANNING IMPLEMENTATION RATIONALE EVALUATION

DIAGNOSIS
S> “ Ang hirap INEFFECTIVE GOAL: 1. Note rate and depth of • To assess the  The client
huminga, para BREATHING After the 4 hours of shift, respirations, type of respiratory status and established
akong PATTERN r/t the client shall be able to breathing pattern if there’s any distress normal breathing
hinihingal.”, as difficulty of establish a normal
2. Assess for pain or • It may limit pattern
verbalized by breathing breathing pattern
the client discomfort respiratory effort
 The client is able
OBJECTIVES:
3. Elevate HOB or have • To promote ease upon to breathe
O > Dyspnea After 1 hour of shift, the
the client sit up breathing and comfortably
>use of client shall be able to:
accessory • Assume minimize distress
4. Encourage the client in
muscles to comfortable  The client is in
a comfortable position • To provide comfort
breathe position semi-fowler’s
>(+)chest pain 5. Administer O2 at • For management of position
>altered v/s: • Breathe comfortably lowest concentration respiratory distress
PR-102bpm with minimal indicated  He is able to
RR-30bpm distress • To provide relaxation demonstrate
6. Assist client with
and to help client cope relaxation
• Demonstrate relaxation techniques
with the condition
relaxation techniques
techniques or
coping behaviors

S> “Nawawalan IMBALANCED GOAL: After 5hours of  Client verbalized

na tuloy ako ng NUTRITION r/t duty, the patient will be 1. Ascertain client’s • To determine understanding of
ganang kumain” loss of apetite able to demonstrate understanding of informational needs good nutrition
as verbalized by behaviors or lifestyle individual nutritional of client  Patient is able to
the client changes to maintain a needs demonstrate
balanced nutrition • To determine ability lifestyle changes
O>thin cheeks, OBJECTIVES: 2. Note availability of to acquire various to maintain a
with prominent The patient will be able financial resources or types of food balanced
cheek bones to: financial status of the nutrition
> thin • Verbalize client • To appeal to client’s  Client’s weight is
extremities understanding of 3. Discuss eating habits likes/dislikes normal for his
>decreased good nutrition and food preferences age
fat/muscle mass of client • To help determine  Client
>eats few and is • Maintain 4. Note age, body build, nutritional needs increased his
not able to appropriate weight strength, etc. • To stimulate appetite fluid intake
finish even half for age 5. Encourage client to  Client is able
of his meal choose food • To enhance intake to finish 1/3 of
• Increase his 6. Promote pleasant and and to have positive his food
appetite relaxing environment; effect on eating
avoid unpleasant odor
• Increase fluid or sight • For client to
intake 7. Emphasize understand
importance of having importance and to
nutritious intake promote wellness
• To prevent aspiration
8. Emphasize need to
and to facilitate
increase fluid intake
swallowing of the
and to drink water
client
while eating
S> “” as SLEEP GOAL:
verbalized by DEPRIVATION After 8 hours of shift, the 1. Determine presence of • To know the factors  Client was able
the client r/t breathing client should be able to physical or that deprives the to adjust his
discomfort adjust lifestyle to psychological sleeping pattern of the lifestyle to
O> restless promote good sleep stressors, pain, current client promote sleep
>Slowed illness, etc  Client was able
reaction OBJECTIVES: • To have a to verbalize he
> lacked After 4 hours of shift, the 2. Determine the client’s comparative baseline understanding
energy client shall be able to: usual sleep pattern and data of the
>decreased • Verbalize expectations importance of
ability to understanding of sleep
function importance of 3. Assess for physical • To know if Px is  Client was able
>presence of sleep signs of fatigue experiencing to identify
eye bags • Report fatigability appropriate
improvement in 4. Encourage client to interventions to
sleep- rest pattern restrict caffeine, • These factors disrupt promote sleep
• Identify alcohol, and other sleep patterns  Client was able
appropriate stimulating substance to report
interventions to 5. Recommend quiet • To reduce stimulation improvement in
promote sleep activities such as so that client will be his sleep-rest
reading or listening to able to relax pattern
music in the evening
6. Instruct in relaxation • To decrease tension
techniques
7. Provide calm, quiet • To reduce stimulation
environment for the and enhances sleep
client