Name: R.P.G Age: 73 Gender: F Nationality: Filipino AP: Dr.

Gutierrez Dx: AGE t/c Electrolyte Imbalance

Religion: Catholic

CUES

NURSING DIAGNOSIS

NURSING CARE PLAN OBJECTIVES OF CARE PLAN OF INTERVENTIONS Assessed General status of pt

RATIONALE

EVALUATION SCHEME

O> (+) Edema (-) Skin Turgor (+) Bed ridden (+) Bruises (+) Bed Sores

For prioritization of patients needs For continuous monitoring To maintain safety

Kept safe and comfortable Ensured side rails remained up Monitored IVF P1: Within the shift, A1: Risk for injury
patients family will express an understanding of having a careful watch on the patient and the importance of not leaving her alone.

For continuous monitoring

Goal met

Vital signs q4h and recorded For comfort and to prevent bed sores Use of pillows in on bony prominent areas of the body Turned side to side q3h Due meds given as ordered NGT done c SAP NGT checked for placement and patency prior to feeding To help remove excess mucus to improve breathing process To meet their clinical needs To prevent aspiration For safety of patient to prevent aspiration

P1: Within the shift, the patients family will express an understanding on ways to prevent falls once the patient is discharged.

O>

P2: Within 4hours, the

(+) Fever 40.0 A2: Fever r/t infection

patients temperature will decrease to 38.5c

Health teaching to relatives on chest clapping after administering nebulizer Advised relative to give TSB PRN Informed nurse of fever state

To lower body temperature To administer prescribed IV meds for fever For continued monitoring To decrease edema

Goal not met : Temperature of 39.4

O> (+) Edema on upper extremities A3: Fluid Volume Excess

P3: Within the shift, edema will decrease

Checked temperature q2h

Goal not met

o> (+) Inspiratory Crackles on both lung fields RR: 30cpm A4: Ineffective airway clearance r/t thick sputum

P4: Within the shift, the clients respiratory rate will be within normal range.

Applied warm compress on edematous areas q2h

Provides a basis for evaluating adequacy of ventilation
Presence of nasal flaring and use of accessory muscles of respirations may occur in response to ineffective ventilation As fluid and mucus accumulate, abnormal breath sounds can be heard including crackles and diminished breath sounds owing to fluid-filled air spaces and diminished lung volume

Goal Met: RR= 20cpm

Monitor rate, rhythm, depth, and effort of respirations

Note chest movement, watching for symmetry, use of accessory muscles, and supraclavicular and intercostal muscle retractions.

Auscultate breath sounds, noting areas of decreased or absent ventilation and presence of adventitious sounds

Assists in evaluating prescribed treatments and client outcomes Auscultate lung sounds after
Respiratory tract infections alter the amount and character of se-

treatments to note results Monitor clients ability to cough effectively

cretions. An ineffective cough compromises airway clearance and prevents mucus from being expelled People with pneumonia commonly produce rustcolored, purulent sputum

Monitor clients respiratory secretions.

Position patient on semi fowler position

Lying flat causes the abdominal organs to shift toward the chest, crowding the lungs and making it more difficult to breathe

To help minimize the amount of secretions that are loosened from nebulization Suctioning after nebulization