Appendix B NURSING CARE PLAN

Name:E.V.B. Date of Admission :July 17, 2018 7:18 pm

Age:60 years old Room Number :MM4

Impression: Hospital Number :xxxxx

Attending Physician :MBSC, MD

Diagnosis:Chronic Obstructive Pulmonary Disease secondary to
CVD Infarct Student Nurse’s Name :Jessa Mae Nina C. Potot

Signature :

Assessment: Chief Complaint:mild chest tightness

History of present Illness:

A case of E.V.B. 60 years old, male, married, Roman Catholic,

residing at YlayaMarigondonLapu-Lapu City, came in due to
sudden onset of dyspnea. Patient also states he gets cramping in
his right calf when he walks.Patient opted to rest and later on
decided to go for admission due to mild chest tightness.

Past Health History Relevant to Present Illness:

Patient is hypertensive. Patient is non-diabetic, smoker,

Significant Findings: occasionally drink alcohol beverages, no drug allergiesand
Segmented Neutrophil – 78% (High) allergic of foods like seafood. Patient has a long standing history
Lymphocyte – 15% (Low) of COPD secondary to tobacco use. He used to smoke 20 sticks
Hemoglobin – 13.2g/dL (Low) per day. Paternal side is diabetic and hypertensive and lung
Hematocrit – 39.3% (Low) cancer. Maternal side is cardiovascular disease. Laboratory
HbA1c – 10.20% (High) examinations such as CBC, Urinalysis, X-raywere done.
V/S During Admission:
BP : 180/80mmHgHR/PR : 80bpm
Temp : 35.5°CRR :20cpm

Diagnostic Procedure

 Urinalysis

Macroscopic
Color Light Yellow
Appearance Hazy
Specific Gravity 1.010
pH 6.0
Bilirubin Negative
Urobilinogen Negative
Ketones Negative
Protein TRACE
Nitrite Negative
Glucose +++
Hematology Section
Test Name Result Significant Findings
WBC 10.9 High
Segmented 78 High
Neutrophil
Monocyte 15 Low
Eosinophil 0 Normal
Basophil 0 Normal
Total Diff 100
RBC 4.8 Normal
Hemoglobin 13.2 Low
Hematocrit 39.3 Low
MCV 81.7 Normal
MCH 27.4 Normal
MCHC 33.6 Normal
RDW-CV 15.2 Normal
Clinical Chemistry
Potassium 3.5-5.1 3.6 mmol/L Normal
Sodium 137-145 144.0 mmol/L Normal
Creatinine 0.80-1.50 1.0 mg/dL Normal
SGPT (ALT) <50 16.02 u/L Normal
HbA1C 4.3-6.4 10.20 % High
Cues / Nursing Scientific Basis Outcome Criteria Nursing Rationale Evaluation
Evidences Diagnosis Intervention
Ineffective After 8 hours of After 8 hours of
Objective airway nursing  Monitor  Indicative of nursing
clearance intervention the respiration respiratory intervention the
 Chang related to patient will be able and distress and patient was able
es in increased to: breath accumulation to:
respira production sounds of secretions.
tory of  Maintain noting  Maintained
rate or secretions airway rate and airway
rhythm patency sounds patency
 Restles with breath (e.g. with
sness sounds tachypnea breath
 Cyanos clear. , stridor, sounds
is  Demonstrat crackle, clear.
e behaviors wheezes)  Demonstra
to improve  Evaluate  To determine tedbehavi
airway clients ability ors to
clearance cough/gag toprotect improve
such as reflex and own airway airway
cough swallowin clearance
effectively g ability. such as
and  Position  To maintain cough
expectorat head open airway I effectively
e secretion. according at rest or and
 Expectorat to age or compromised expectorat
e or clear condition individual. e
secretions  Suction  To clear secretion.
readily. naso, airway when  Expectorat
 Identify tracheal or excessive or ed or clear
potential oral as viscous secretions
complicatio needed secretions readily.
ns and how are blocking  Identified
to initiate airway or potential
appropriate client is complicati
Cues / Nursing Scientific Basis Outcome Criteria Nursing Rationale Evaluation
Evidences Diagnosis Intervention
preventive unable to ons and
or swallow or how to
corrective cough initiate
actions effectively. appropriat
 Encourage  To maximize e
deep effort preventive
breathing or
and correctivea
coughing ctions
exercise
 Support  To improve
reduction lung function
or
cessation
of
smoking
 Auscultate  To
breath ascertain
sounds status ad
and note
assess air progress
movement
 Observe
for signs  To
and identify
symptoms infectious
of process
infection or timely
(e.g. interventi
increased on
dysnea
with onset
of fever,
Cues / Nursing Scientific Basis Outcome Criteria Nursing Rationale Evaluation
Evidences Diagnosis Intervention
change
sputum
color,
amount or
character)
 Encourage  Prevent
or provide or
opportunit reduces
ies for fatigue
rest. Limit
activities
to level of
respiratory
tolerance
Cues / Nursing Scientific Basis Outcome Criteria Nursing Rationale Evaluation
Evidences Diagnosis Intervention
Cues / Nursing Scientific Basis Outcome Criteria Nursing Rationale Evaluation
Evidences Diagnosis Intervention
Cues / Nursing Scientific Basis Outcome Criteria Nursing Rationale Evaluation
Evidences Diagnosis Intervention
Subjective Imbalance Short-Term Goal:  Ascertain  To Short-Term Goal:
Nutrition: understan determin
Objective Less than After 8 hours of ding of e After 8 hours of
Loss of weight body nursing indivual informati nursing
with adequate requiremen intervention the nutritional onal intervention the
food intake ts related patient will be able needs needs of patient was able
to fatigue to: client or to:
 Display significan  Displayed
progressive t other progressiv
weight gain  Assess  That may e weight
toward drug be gain
goal as interaction affecting toward
appropriate s, disease appetite, goal as
 Demonstrat effects, food appropriat
e behaviors allergies, intake or e
or lifestyle use of absorptio  Demonstra
changes to laxatives n ted
regain and or behaviors
maintain diuretics. or lifestyle
appropriate  Determine  To assess changes to
weight psychologi body regain and
 Verbalize cal factor image maintain
understand or perform and appropriat
ing of surgical congruen e weight
causative assessme cy of  Verbalized
factors nt. reality understan
when  Limit fiber  Because ding of
known and or bulk if it may causative
necessary indicated lead to factors
interventio early when
n satiety known
 Promote  To and
pleasant, enhance
Cues / Nursing Scientific Basis Outcome Criteria Nursing Rationale Evaluation
Evidences Diagnosis Intervention
relaxing intake necessary
environme interventio
After 1 week of nt n
nursing including
intervention the socializatio
patient will be able n when
to: After 1 week of
possible nursing
 Display  Promote  To intervention the
normalizati adequate reduce patient was able
on of or timely possibility to:
laboratory fluid of early
values and intake. satiety  Displayed
be free of Limit normalizati
signs of fluids 1 on of
malnutritio hour prior laboratory
n to meal values and
 Weigh  To be free of
results or monitor signs of
graph effectiven malnutritio
regularly ess of n
efforts
 Recomme  For
nd or controlled
support environm
hospitaliza ent in
tion severe
malnutriti
on or
life-
threateni
ng
situations
Cues / Nursing Scientific Basis Outcome Criteria Nursing Rationale Evaluation
Evidences Diagnosis Intervention
Subjective Impaired The compensatory Short term goal:  Evaluate  To assess Short term goal:
Gas mechanism of lung pulse for
Objective Exchange is to lose After 8 hours of oximetry respirator After 8 hours of
 Restles related to effectiveness of its nursing to y nursing
sness aveolar- defense mechanisms intervention the determine insuficien intervention the
 Irritabi capillary and allow patient will be able oxygenati cy patient was able
lity membrane microorganism to to: on, to:
 Difficul changes penetrate the sterile evaluate
ty lower respiratory  Demonstrat lung  Demonstra
Breathi tract where e absence volume ted
ng inflammation of and forced absence of
 Cyanos develops. Disruption respiratory vital respiratory
is of mechanical distress capacity distress
 Abnor defenses and ciliary  Verbalize  Evaluate  To  Verbalized
mal motility leads to understand head of maintain understan
breathi colonization of lungs ing of bed or airway ding of
ng and subsequent causative position causative
infection. Inflamed factors and client factors
and fluid-filled appropriate appropriat and
alveolar sacs cannot interventio ely, appropriat
exchange oxygen ns provide e
and carbon dioxide  Participate airway interventio
effectively.The in adjuncts ns
release of treatment and  Participate
endotoxins by the regimen suction as d in
microbes can lodge (e.g indicated treatment
in the brain, breathing  Encourage  Promotes regimen
affecting the exercises, frequent optimal (e.g
respiratory center in effective position chest breathing
medulla resulting to coughing, changes expansio exercises,
altered supply use of and deep n effective
oxygen. oxygen) breathing coughing,
within level coughing use of
Cues / Nursing Scientific Basis Outcome Criteria Nursing Rationale Evaluation
Evidences Diagnosis Intervention
Source: Scribd.com of ability exercises oxygen)
or  Maintain  For within
situation) adequate mobilizati level of
input and on of ability or
Long term goal: output secretion situation)
After 1 week of s. But
nursing avoid Long term goal:
intervention the fluid After 1 week of
patient will be able overload nursing
to:  Encourage  Help limit intervention the
 Demonstrat adequate oxygen patient was able
e improve rest and needs to:
ventilation limit and  Demonstra
and activities consumpt ted
adequate to within ion. improve
oxygenatio client ventilation
n of tissues tolerance. and
by ABGs Promote adequate
within calm/restf oxygenatio
client’s ul n of
normal envronme tissues by
limits. nt ABGs
 Provide  To within
psyhologic reduce client’s
al support, anxiety normal
active- limits.
listener to
questions/
concerns
.  Keep  To
environme reduce
nt allergen irritant
or effects of
Cues / Nursing Scientific Basis Outcome Criteria Nursing Rationale Evaluation
Evidences Diagnosis Intervention
pollutant dust and
free chemicals
on
airways
 Review  To
risk promote
factors, preventio
particularl n or
y manage
environme ment of
ntal or risk
employme
nt related
 Encourage  To
cliend and reduce
significant health
other to risk and
stop prevent
smoking, further
attend decline in
cessation lung
programs function
as
necessary
 Emphasize  For
the improvin
importanc g stamina
e of and
nutrition reducing
the work
of
breathing