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UNIVERSITY OF PERPETUAL HELP SYSTEM DALTA LAS PINAS

COLLEGE OF NURSING

NURSING CARE PLAN


1.Ms, N.R.
ASSESSMENT
CUES
Objective Cues:
-(+) fever
-(+) diarrhea
-with dry mucous
membranes
-sunken eyes
-hot and dry skin
-poor skin turgor
-PR 140 bpm
-RR 32 cpm

NURSING
DIAGNOSIS

PLANNING and
OUTCOME

Risk for fluid volume


deficit as evidenced
by dehydration may
be related to
diarrhea.

After giving nursing


intervention the
client will not
experience fluid
volume deficit as
evidenced by:
- normal skin turgor
-moist mucous
membranes

NURSING INTERVENTION
Selected
Implemented
-monitor intake and
output

-To find out the balance


of fluids in the body
that are needed for
daily metabolism.

-Monitor skin turgor.

-To find out the less


interstitial fluid / loss
can lead to loss of skin
elasticity.

-Monitoring of urine.
-The reduced amount of
urine as indicators of
reduced fluid in the
body.
-increase oral fluid
intake up to 3 L/min if
not contraindicated
-Assess the
individual's
understanding of the
reasons to maintain
adequate hydration
and methods for
achieving goals fluid
intake.

2. MR. JOHN

RATIONALE

-to promote rehydration


and elimination of
microorganisms.
-to give appropriate
intervention that the
patient is capable and
willingness to
cooperate.

EVALUATION

ASSESSMENT
CUES
Objective Cues:
-persistent cough
-dyspneic
-warm, dry skin
-RR 28 BPM
-with nasal cannula
at 6L/min.
-(+) fever

NURSING
DIAGNOSIS
Ineffective airway
clearance as
evidenced by
dyspnea and
persistent cough.

PLANNING and
OUTCOME
After giving 8 hours
of nursing
intervention, the
patient will be able
to identify and/or
demonstrate
behaviours to
achieve airway
clearance.

NURSING INTERVENTION
Selected
Implement
ed
-Assess the rate and
depth of respirations and
chest movement.

-Auscultate lung fields,


noting areas of decreased
or absent airflow and
adventitious breath
sounds: crackles,
wheezes.

-Elevate head of bed,


change position
frequently.

-Teach and assist patient


with proper deepbreathing exercises.
Demonstrate proper
splinting of chest and
effective coughing while
in upright position.
Encourage him to do so

RATIONALE

-Tachypnea, shallow
respirations, and
asymmetric chest
movement are frequently
present because of
discomfort of moving chest
wall and/or fluid in lung.
-Decreased airflow occurs
in areas with consolidated
fluid. Bronchial breath
sounds can also occur in
these consolidated areas.
Crackles, rhonchi, and
wheezes are heard on
inspiration and/or
expiration in response to
fluid accumulation, thick
secretions, and airway
spams and obstruction.
-Doing so would lower the
diaphragm and promote
chest expansion, aeration
of lung segments,
mobilization and
expectoration of secretions.
-Deep breathing exercises
facilitates maximum
expansion of the lungs and
smaller airways. Coughing
is a reflex and a natural
self-cleaning mechanism
that assists the cilia to

EVALUATION

often.

-Assist and monitor


effects of nebulizer
treatment and other
respiratory physiotherapy:
incentive spirometer,
IPPB, percussion, postural
drainage.

maintain patent airways.


Splinting reduces chest
discomfort and an upright
position favors deeper and
more forceful cough effort.
-Nebulizers and other
respiratory therapy
facilitate liquefaction and
expectoration of secretions.