NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS EVALUATION

NOTE: usually, the After two hours of nursing
Subjective Data: Ineffective breathing The patient has pleural rationale already serves as intervention, the goal was
pattern related to effusion which is the the explanation for the MET when the client was
“Nahihirapan ako sa accumulation of fluid in abnormal accumulation of interventions, so aside for able to experience
paghinga kaya minsan ay the lungs as evidenced by fluid in the pleural cavity. additional info pa in case improvement in breathing
hirap din ako kumilos, deep inspiration and use of So, based on our diagnosis matanong, always think and manage fluid drainage
hindi ako makagawa ng accessory muscle when our goal for this problem is kung paano mo ginawa through JP drain.
mga gawaing bahay” breathing to maintain effective yung interventions, paano
breathing and reduce the mo inapply sa patient, and JP drain output
Objective Data: The patient`s airway is fluid build up. How can we ano yung nakita mo na July 11 8 am: 100 cc
Vital signs: always the priority. The reduce the fluid build up? reason bakit yun ang July 11 4 am: 20 cc
Temperature: 36.7 patient`s chief complaint As you can see, the patient interventions na ginawa
PR: 107 bpm upon admission is currently has a JP drain, mo. Oxygen saturation from
RR” 20 cpm difficulty of breathing and which helps para 94% to 96%
SaO2: 94% a week passed, during our mabawasan yung fluids sa So we have our
BP: 110/80 mmHg assessment, the patient lungs. Our intervention for independent nursing After three days or nursing
stated that she still that will mostly focus on interventions such as: interventions, the goal was
- Use of accessory experienced difficulty of monitoring the output sa JP MET, when the patient was
muscle during deep breathing especially when drain to see if there are any 1. Monitor vital signs, able to verbalize
breathing moving or doing her changes associated with the noting changes in understanding of the
- Deep inspiration activities of daily living. patient`s current condition. respiratory rate, causative factors and
- (+) JP drain This diagnosis is supported blood pressure, and appropriate interventions to
- (+) pleural rub by our objective data such Short term: heart rate. maintain a patent airway.
as the use of accessory
muscles, deep inspiration, After two hours of nursing Rationale: provides So upon our assessment
the presence of pleural rub interventions, the client baseline data and interventions, naging
upon assessment and JP will be able to: influencing the effective yung plan since
drain to remove the fluid choice of naipakita ni patient yung
build up in the lungs. 1. Maintain airway interventions. health teaching na ginawa
patency and reduce which is also included sa
fluid build-up in the For the entire three days discharge plan.
lungs. that we conducted our
2. Maintain oxygen assessment, we monitored
saturation greater our patient`s vital signs
than 94%. Upon especially the respiratory
our first rate and oxygen saturation.
 assessment, the Luckily, we saw an
patient`s oxygen improvement in the
saturation is 94% patient`s vital signs.
and with our
interventions, we 2. Monitor respiratory
want to see status. Regularly
improvement with assess respiratory
the patient`s rate, depth and
oxygen status. effort.

Long term: Rationale: to

evaluate indications
After three days of nursing of respiratory
interventions, the client distress.
will be able to: Considering the patient`s
condition, monitoring the
We believe that three days patient`s status is essential.
is enough to achieve our For three days, we
long term goals which is to performed auscultation
1. Maintain effective noting signs of respiratory
breathing pattern distress. (pa search na lang
and demonstrate signs ng respiratory
behavior to distress in case matanong
improve airway. AHAHAHA)
2. Verbalize
understanding of 3. Elevate head of the
causative factors bed, encouraging
and appropriate early ambulation
interventions. and change in
client`s position.
With these long term goals,
we will be performing Rationale: to
health teaching so the promote
patient can maintain physiological and
improvement in breathing psychological ease
and prevent any further of maximal
complications. inspiration.

We instructed the patient

na kapag hirap siya
huminga, need i-elevate
ang head niya at least 45
degrees either i-adjust ang
bed or gumamit ng pillows
para mabawasan ang
pressure sa chest and mag
open yung airways.

4. Regularly assess
and record the
amount, color and
consistency of
drainage form the
JP drain.

Rationale: to
prevent bleeding or
blockage. It ensures
that the drain
remains patent and
functional.
As mentioned earlier, the
patient has an
accumulation of fluid in
the lungs, and one
intervention necessary or
related to this is to assess
the drainage output sa JP
drain kung saan napupunta
yung fluid sa lungs. To
prevent any complications,
we instructed the patient na
i-monitor and i-take note
yung output ng drain kasi
magseserve din yun as
baseline data para malaman
if may improvement ba ang
condition ni patient.
 5. Encourage adequate
rest and limit
activities within the
client`s tolerance.

Rationale: helps
limit oxygen needs
and consumption.

In our interventions, we
encouraged the patient na
huwag ipilit gumawa ng
isang activity if it will
compromise her airway.
Our patient can
independently perform
activities of daily living but
in our health teaching, we
emphasized the important
to taking adequate rests
and asking for assistance if
hindi kaya.

6. Teach client about

relaxation
techniques.

Rationale: to reduce
anxiety and
promote effective
breathing.

Techniques include getting

restful sleep (especially
naka note sa doctor`s order
na meron siyang insomnia
and nagprescribe ng
melatonin), eating healthy
 diet, listening to a calming
music, deep breathing, etc.

(sa deep breathing be

mindful na lang kasi may
chest pain si patient and
ang sabihin na lang or
ipalabas na ineducate natin
si patient ng deep breathing
but be conscious na lang, if
nakakaramdam ng chest
pain, itigil na)

Subjective Data: Chronic pain related to Short term: Independent: After eight hours of
“Sobrang sakit na para chest and lower back pain nursing intervention, the
akong tinutusok-tusok sa as evidenced by 7/10 pain After eight hours of 1. Routinely monitor patient was able to
likod at dito sa dibdib kaya scale, facial grimace and nursing intervention, the the client`s vital verbalize pain relief.
ang hirap kumilos.” guarding behavior patient will be able to: signs.
For the past eight hours,
Provocation: patient We chose pain as our 1. Verbalize pain Rationale: to assess the patient was able to take
reports chest and back pain second priority for our ncp relief or control and be tramadol for pain relief and
that gets worse while because even though of pain or knowledgeable aside from that, our
moving or performing deep chronic na, we wanted to discomfort about the primary intervention such as
breathing. perform interventions that through data and the assisting the patient in
Quality: stabbing pain will lessen yung pain na administration possible changes in performing ADLs, ay
Region: lower back pain nararamdaman niya. There of pain the patient`s vital nakatulong din para
Severity: 7/10 are different factors kung medication as signs. mamanage ang pain.
Why 7/10? Upon bakit siya prescribed.
admission, pain scale ni nakakaexperience ng pain 2. Assess and
patient is 10/10 daw however, dahil pabalik- Long term: document the After three days of nursing
however, our assessment balik nga, the focus of our client`s pain intervention, the patient
started last July 11, a week interventions will be more After three days of nursing tolerance, was able to adhere to
after admission. It was on the management of pain interventions, the patient characteristic, prescribed pharmacological
expected na nag lessen na through pain meds and will be able to: intensity, location, management.
yung pain ni patient kasi health teaching. aggravating and
nagkaroon na ng 1. Follow prescribed alleviating factors We also included health
management regarding that pharmacological of pain. teaching which is
which is yung pagtake niya regimen to manage Rationale: to help successful and for the past
ng pain medications. pain. evaluate the nursing three days, the pain scale is
 interventions, that 6 or 5/ 10.
Timing: the pain started the patient needs
last year and keep track the
status of the
Associated factors of pain: patient`s pain.
age, stress, poor posture,
For 1 and 2, for
Objective data: three days we
Temperature: 36.7 continuously assess
PR: 107 bpm the patient`s vital
RR” 20 cpm signs and her
SaO2: 94% perception of pain.
BP: 110/80 mmHg In the second
intervention, we
- Guarding behavior made the patient
- Facial grimace feel na valid yung
- (+) tachycardia pain na nafifeel
niya. And with that,
through this
intervention,
nalaman namin na
nakaka experience
na pala si patient ng
pain for years….
Please refer na lang
po sa pqrst
assessment for
further info
HAHAHAHAH

3. Assist the patient in

performing
activities of daily
living.

Rationale: chronic
pain may impact
the patient`s ability
to perform ADLs.
 Assisting the
patient may help
maintain a sense of
independence and
autonomy.

Due to her age and

current condition,
her ADLs are also
affected so with this
intervention, we
informed the
patient na kapag
kumikilos, huwag
masyado i-pwersa
ang katawan
because it may
cause more pain, so
instead, we
educated her that
she also needs to
ask for an
assistance to
promote her safety
and hindi na
madagdagan pa ang
pain na
nararamdaman
niya.

4. Educate client on
pain management
including
medication side
effects an
complications.

Rationale: help the

patient know what
 to watch out for
when taking pain
medications.

The patient is
taking tramadol as a
take home med, so
in this intervention,
we included a
health teaching
about this pain
medication, if para
saan, kailan dapat i-
take, the possible
side effects that she
will experience, etc.
the patient and the
relatives actively
participated in this
health teaching.

Dependent:

1. Administer pain
medication as
prescribed.
- Tramadol 50 mg IV
q8h

Rationale: to
manage persistent
pain and to find
relief and increase
level of function.