NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE:
Impaired Gas Within 8H of Assessment:
“sige ug hilak unya Exchange r/t Nursing 1. Assess and record respiratory 1. The average rate of respiration for infants 25-55 After 8H of
maglisod sya ug decreased intervention the rate and depth at least every 4 breaths per minute. It is important to take action when Nursing
ginhawa” as verbalized functional lung Patient’s hours. there is an alteration in the pattern of breathing to intervention the
by the mother. tissue respiratory rate detect early signs of respiratory compromise. patient’s
secondary to remains within respiratory rate
OBJECTIVE:
pneumonia established limits. 2. This monitors oxygenation and ventilation status. remained within
 V/S upon admission established limit.
T-39.7 °C 2. Assess ABG levels, according to
P-178 bpm facility policy. 3. Unusual breathing patterns may imply an underlying RR:40breaths/min
O2 Sat- 75% disease process or dysfunction. 02 Sat: 95%
 Dyspnea 3. Observe for breathing patterns.
 Tachypnea 4. This is to detect decreased or adventitious breath
 Tachycardia sounds. Work of breathing increases greatly as lung
 Restless and 4. Auscultate breath sounds at compliance decreases.
irritable least every four (4) hours. Assess
 Infiltrates seen on for use of accessory muscle. 5. Paradoxical movement of the abdomen (an inward
chest x-ray film versus outward movement during inspiration) is
 Reduced vital 5. Monitor for diaphragmatic indicative of respiratory muscle fatigue and weakness.
capacity muscle fatigue or weakness
(paradoxical motion). 6. These signs signify an increase in respiratory effort.

6. Observe for retractions or 7. An elevated position permits maximum lung excursion

flaring of nostrils. and chest expansion.

Therapeutic:
7. Place patient with proper body 8. This is to clear blockage in airway.
alignment for maximum
breathing pattern. 9. Moving air can decrease feelings of air hunger.

8. Suction secretions, as necessary.

9. Avail a fan in the room.

 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE:
Risk for bleeding Within 8H of Assessment:
“Gi anemic man pudd r/t low Nursing 1. Assess the skin for bruises and 1. Bruises and petechiae is usually evident when the After 8H of
aw ni maong hematocrit intervention the petechiae. platelet count drops to 20,000 mm3. Nursing
giabonohan ug dugo” as count secondary client will have a intervention the
verbalized by the to Severe reduced risk for 2. Assess for any frank bleeding 2. Early assessment facilitates immediate treatment. client did not have
mother. Anemia bleeding, as from the nose, gums, vagina, or These sites are most common for spontaneous a reduced risk for
evidenced by urinary or gastrointestinal tract. bleeding. bleeding, as
OBJECTIVE:
normal or evidenced by
 Pale skin adequate platelet 3. Monitor platelet count. 3. A low platelet count or thrombocytopenia is caused by abnormal lab
 Appears weak levels and absence a bone marrow malfunction resulting from nutritional results.
 Minimal activity of bruises and deficiencies, drugs, certain viral causes, or aplastic
petechiae. anemia. The risk for bleeding is increased as platelet  Low Hbg, Hct,
 Lab Results: count is decreased. RBC,
 Hbg: 91 g/L ↓  High platelet
 Hct: 0.273 g/L↓ 4. Consolidate laboratory blood 4. Repeated blood sampling over time can lead to count
 RBC: 3.85 sampling test. anemia. Consolidation minimizes the number of
 MCV: 70.9 ↓ venipunctures and optimizes blood volume. GOAL NOT MET
 MCH: 23.7 ↓
5. Monitor patient’s vital signs, 5. Hypotension and tachycardia are initial compensatory
 MCHC: 335 g/L
especially BP and HR. Look for mechanisms usually noted with bleeding. Orthostasis
 WBC: 9.59
signs of orthostatic (a drip of 20 mm Hg in systolic BP or 10 mm Hg in
 Neutophils: 55.3
hypotension. diastolic BP when changing from supine to sitting
 Lymphocytes: 28.3
position) indicates reduced circulating fluids.
 Monocytes: 15.7 ↑
 Eosonophils: 0.1 ↓ 6. Monitor hematocrit (Hct) and 6. When bleeding is not visible, decreased Hgb and Hct
 Basophils: 0.6 hemoglobin (Hgb). levels may be an early indicator of bleeding.
 Platelet: 689 ↑
Therapeutic:
7. Educate the at-risk patient 7. Information about precautionary measures lessens the
about precautionary measures risk for bleeding.
to prevent tissue trauma or
disruption of the normal clotting
mechanisms.
8. When laboratory values are 8. Blood product transfusions replace blood clotting
abnormal, administer blood factors; RBCs increase oxygen-carrying capacity; FFP
products as prescribed. replaces clotting factors and inhibitors; platelets and
cryoprecipitate provide proteins for coagulations.

9. Educate the patient and family 9. Early evaluation and treatment of bleeding by a health
members about signs of care provider reduce the risk for complications from
bleeding that need to be blood loss.
reported to a health care
provider.

10. Monitor for skin necrosis, 10. Patient on anticoagulant therapy remains at risk of
changes in blue or purple developing emboli.
mottling of feet that blanches
with pressure or fades when
legs are elevated.

11. Inform the patient to check the 11. Bright red blood in the stools is an indicator of lower
color and consistency of stools. gastrointestinal bleeding. Stool that has a dark
greenish-black color and a tarry consistency is linked
with upper gastrointestinal bleeding.