URDANETA CITY UNIVERSITY

San Vicente West, Urdaneta City, Philippines-2428

COLLEGE OF HEALTH SCIENCES

STUDENT NURSING CARE PLAN

Name of Student: _____________________________________ Date: ____________________

Affiliating Hospital: ______________________________ Year/Level: _______________

Name of Patient: ________________________________ Ward/Area/Room: ____________________________

Admitting Diagnosis: ____________________________ Date/Time of Admission: ________

Age: ______________ Sex: ______________________ Civil Status: __________________
Nationality: ____________________________________ Date of Birth: _________________
Address _______________________________________ Dialect Spoken: _______________
Chief Complaint: _________________________________ Attending Physician:
____________________________
Final Diagnosis: _____________________________ Date/Time of Discharge: ________

ASSESSMENT DIAGNOSIS OUTCOME/OBJECTIVE/ INTERVENTION/S RATIONALE EVALUATION

S

(+) dyspnea Impaired gas Patient will maintain  Assess  Manifestation of Patient maintain optimal gas
(+) abnormal exchange RT optimal gas exchange after respirations; respiratory exchange as evidence by
breath collection of 4-6 hours of providing note quality, distress are normal respiration,(-)
Restlessness mucus in nursing interventions rate, rhythm, dependent dyspnea, effective coughing
(+) productive airways depth, use of on/and indicative technique
cough accessory of the degree of
Vital Signs: muscles, ease, lung involvement
Respiratory Rate- and position and underlying
35bpm assumed for general health
Pulse Rate- easy breathing status as patient
128bpm will adapt their
Blood Pressure- breathing
120/70mmHg patterns to
Temperature- facilitate
36.6*C/Axilla effective gas
exchange
 Elevated head  These measure
 and encourage promote
frequent position maximum chest
changes, deep expansion,
breathing, and mobilize
effective secretions and
coughing improve
ventilation

Checked by:

_____________________ APRIL G. ALAP, RN., PhDNEd.

Student Nurse Clinical Instructor