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  • Nursing Care Plan: Assessment Diagnosis Planning Intervention Rationale Evaluation

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    Adelaine Loresto
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    The nursing care plan assessed an ineffective breathing pattern and activity intolerance in a patient with community acquired pneumonia. Vital signs on admission showed an increased respiratory rate of 24 breaths per minute. The plan was to monitor vitals and encourage deep breathing exercises to improve breathing to 20 breaths per minute within 4 hours. Medications would also be administered. A second assessment found difficulty breathing was gradually reducing and the goal of participating in activities was met, with vital signs stable.

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    Medical

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    NCP for Ineffective Breathing Pattern

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    The nursing care plan assessed an ineffective breathing pattern and activity intolerance in a patient with community acquired pneumonia. Vital signs on admission showed an increased respiratory rate of 24 breaths per minute. The plan was to monitor vitals and encourage deep breathing exercises to improve breathing to 20 breaths per minute within 4 hours. Medications would also be administered. A second assessment found difficulty breathing was gradually reducing and the goal of participating in activities was met, with vital signs stable.

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    Download as DOCX, PDF, TXT or read online from Scribd
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    2K views2 pages

    Nursing Care Plan: Assessment Diagnosis Planning Intervention Rationale Evaluation

    Uploaded by

    Adelaine Loresto
    The nursing care plan assessed an ineffective breathing pattern and activity intolerance in a patient with community acquired pneumonia. Vital signs on admission showed an increased respiratory rate of 24 breaths per minute. The plan was to monitor vitals and encourage deep breathing exercises to improve breathing to 20 breaths per minute within 4 hours. Medications would also be administered. A second assessment found difficulty breathing was gradually reducing and the goal of participating in activities was met, with vital signs stable.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
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    of 2

    NURSING CARE PLAN

    ASSESSMENT
    SUBJECTIVE: Marigatan ak makaanges as verbalized by the patient.

    DIAGNOSIS
    Ineffective breathing pattern related to disease condition (Community Acquired Pneumonia) as manifested by increase respiratory rate.

    PLANNING
    After 4 hours of nursing intervention client should be able to manifest effective breathing. From 24 breaths per minute to 20.

    INTERVENTION
    INDEPENDENT Monitor vital signs.

    RATIONALE

    EVALUATION
    Goal partially met.

    To serve as a baseline data.

    OBJECTIVE: Restlessness Use of accessory muscles Cough

    Raise the head part of the bed.

    To relieve difficulty of breathing.

    Client still manifest difficulty of breathing though it is gradually reduces from 24 breaths per minute to 22. Vital Signs: BP 100/70

    Encourage deep breathing exercises.

    T0 36.20C To promote proper lung expansion. PR 92 RR - 22

    Vital Signs: BP 100/70 T0 36.50C PR 89 RR 24

    DEPENDENT Administer prescribed medication. Helps in aiding effective airway clearance.

    ASSESSMENT
    SUBJECTIVE: Agkakabsut nak, haan ak unay nga makagaraw as verbalized by the patient.

    DIAGNOSIS
    Activity intolerance related to imbalance between O2 supply and demand as manifested by inability to perform ADL.

    PLANNING
    After 4 hours of nursing intervention the client will be able to participate willingly in necessary or desired activities.

    INTERVENTION
    Monitor vital signs.

    RATIONALE
    To serve as a baseline data.

    EVALUATION
    Goal met. Client reveals an increase in activity tolerance.

    Asses clients level of mobility.

    Aids in defining what activities client is capable of.

    OBJECTIVE: Client is mostly lying on bed. Appears to be weak Unable to perform activities of daily living. Asses potential for physical injury.

    Injury maybe related to falls and overexertion.

    To protect client from injury. Assist with activities.

    Vital Signs: BP 100/70 T0 36.50C PR 89 RR - 22

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