NURSING CARE PLAN

ASSESSMENT Subjective - Sa totoo hindi ako kumakain ng tama. Bihira akong kumain ng gulay lalo na ampalaya, minsanminsan ko lang kinakain, verbalized by the patient. DIAGNOSIS Imbalanced nutrition less than body requirements r/t inability to ingest adequate nutrients. PLANNING At the end of the shift, the patient will be able to maintain a good nutrition. INTERVENTION - Monitored vital signs and recorded. - Instructed patient to practice the required diet. - Encouraged patient to eat balanced meals. - Encouraged patient to increase fluid intake. - Provided quiet environment. - Encouraged adequate rest period. - Explained to patients the importance of helping himself to get well soon. - Maintained calm attitude while dealing with the patient and SO. - Monitored I/O. RATIONALE - For baseline data. - So as not to delay the healing process. - To increase nutrients needed by the body. - To increase fluid volume needed by the body. - For relaxation. - To prevent fatigue. - So as to revert back to eating were full diet would be emphasize on his diet. - To limit level of anxiety. EVALUATION Goal partially met as patient show a little progress in the diet needed.

- To compare intake and output result.

NURSING CARE PLAN

ASSESSMENT Subjective - Dumura ako ng dugo pagkatapos kumain, as verbalized by the patient. DIAGNOSIS Ineffective airway clearance r/t increased production of bloody secretions. PLANNING At the end of the shift, the patient will be able to establish a normal/effective airway clearance. INTERVENTION - Monitored vital signs and recorded. - Encouraged pt to cover mouth and nose when coughing. - Encouraged pt to increase fluid intake. - Encouraged pt to cough and sneeze into tissues and dispose properly. - Encouraged adequate rest period. - Encouraged patient to practice deep breathing exercise. - Provided quiet environment. - Monitored I/O. RATIONALE - For baseline data. - Help stop spread of tuberculosis. EVALUATION Goal partially met as the patient verbalized, Medyo okey naman na ako.

- To liquify secretions. - Help stop spread of tuberculosis.

- To prevent fatigue. - To divert his attention. - For relaxation. - To compare intake and output result.

NURSING CARE PLAN

ASSESSMENT Subjective - Nahirapan akong huminga, verbalized by the patient. DIAGNOSIS Ineffective respiratory pattern r/t shortness of breath. PLANNING At the end of the shift, the patient will be able to show progress in her breathing pattern. . INTERVENTION - Monitored and recorded v/s. - Encouraged patient to exercise like deep breathing. - Listened to the patient concerns. - Provided a calm and well ventilated environment. - Encouraged adequate rest period. - Watched out for episodes of DOB. - Monitored I/O. RATIONALE - For baseline data. - To divert his attention. EVALUATION Goal partially met as patient show a little progress in her breathing pattern.

- To enhance trust of the patient. - To assist patient to explore method for relaxation. - To prevent fatigue. - To assist pt in taking control of the situation. - To compare intake and output result.

NURSING CARE PLAN

ASSESSMEN T Subjective - marigatan nak nga umanges, verbalized by the patient. Objective: - Irritability - DOB DIAGNOSIS Impaired gas exchange r/t altered delivery of inspired O2 PLANNING At the end of the shift, the patient will be able: to improve ventilation and oxygenatio n particip ate in treatment regimen (eg.breathi ng exercises) INTERVENTION - Provided well ventilated and restful environment. - Encouraged rest and sleep - Encouraged deep breathing exercises - Watched out for episodes of DOB - Encouraged change in position - Maintained on HBR - To maintain airway - Encouraged to increase fluid intake for at least 6-10 glasses/day w/ aspiration precaution - Rendered bronchial tapping after nebulization - For mobilization of secretions - To assist pt in taking control of the situation. - To divert his attention. RATIONALE - To assist patient to explore method for relaxation. - To prevent fatigue - To divert his attention EVALUATION Goal partially met as patient showed progress in her breathing pattern and oxygenation

- To mobilize
secretions and for the drug to go to all parts of the lung - To treat underlying conditions - For baseline data.

- Administer
medications as indicated (eg. Salbutamol)

- Monitored V/S and

recorded

ASSESSMEN T -

DIAGNOSIS Activity intolerance r/t immobility[

PLANNING At the end of the shift, the patient will be able: to improve ventilation and oxygenatio n particip ate in treatment regimen (eg.breathi ng exercises)

INTERVENTION - Provided well ventilated and restful environment. - Encouraged rest and sleep - Encouraged deep breathing exercises - Watched out for episodes of DOB - Encouraged change in position - Maintained on HBR - Encouraged to increase fluid intake for at least 6-10 glasses/day w/ aspiration precaution - Rendered bronchial tapping after nebulization - Administer

RATIONALE - To assist patient to explore method for relaxation. - To prevent fatigue - To divert his attention - To assist pt in taking control of the situation. - To divert his attention. - To maintain airway - For mobilization of secretions

EVALUATION Goal partially met as patient showed progress in her breathing pattern and oxygenation

- To mobilize secretions and for the drug to go to all parts of the lung - To treat underlying conditions

medications as indicated (eg. Salbutamol)

- For baseline data.

- Monitored V/S and

recorded