X.

Ideal Nursing Care Plan

1. Activity Intolerance r/t Imbalance between oxygen supply (delivery) and demand possibly evidence by weakness and
fatigue.

Independent:

1. Assess pt. ability to perform normal tasks  Influences choice of interventions/ needed assistance
intervention.

2. Monitor BP, pulse, respirations
3. Recommend quiet environment, bed rest if
indicated.
 Cardiopulmonary manifestations result from attempts by the
heart and lungs to supply adequate amounts of oxygen to
the tissues
 Enhances rest to lower body’s oxygen requirements and
reduces strain on the heart and lungs

4. Elevate head of bed as tolerated  Enhances lung expansion to maximize oxygenation for
cellular uptake
Collaborative:

5. Monitor laboratory studies eg. Hbg/Hct. And  Identifies deficiencies in RBC compounds affecting oxygen
RBC count, arterial blood gases (ABGs) transport and treatment needs/ response to therapy.

2. Acute Pain r/t chemical burn of gastric mucosa

Independent:

1. Provide small, frequent meals  Small meals prevent distention and the release of gastrin.

2. Identify and limit foods that create discomfort.  Studies indicated pepper is harmful and coffee (including
decaffeinated)can precipitate dyspepsia.
3. Assist with active and passive range of motion  Reduces joint stiffness, minimizing pain/ discomfort.
exercises.

4. Provide frequent oral care and comfort  Halitosis from stagnant oral secretions is unappetizing and
measures e.g., back rub, position change. can aggravate nausea. Gingivitis and dental problems may
arise.
Collaborative:

5. Provide and implement prescribed dietary  Client may receive nothing by mouth (NPO) initially.
modifications.

X I. Actual Nursing Plan

1.

S Gibati kog kakapoy ma’am.

- Weak in appearance
O - Bedrest
- Dyspnea
- Pallor

A Activity Intolerance r/t Imbalance between oxygen supply (delivery) and demand possibly
evidence by weakness and fatigue.

P At the end of 3- 4hours of nursing interventions, the pt. will be able to improve condition and
participate in desired activities.
 I

E At the end of 3- 4hours of nursing interventions, the pt. was able to improve condition and
participate in desired activities.

2.

S Hapdos ug sakit ako tiyan.

- Weak in appearance
O - Guarding behavior
- Facial grimace
- Pain scale: 7 of 10

A Acute Pain r/t chemical burn of gastric mucosa possibly evidenced by abdominal guarding,
facial grimacing

P At the end of 2- 3hours of nursing interventions, the pt. will be able to verbalize relief of pain and
demonstrate relax body posture.

Independent:

I 1. Assessed pt. pain reports: location;  This will indicate need for various interventions
pain scale; frequency and may signal possible complications.
2. Advised pt to eat small, frequent  Small meals prevent distention
meals

3. Identified and suggested pt to limit  Studies indicated pepper is harmful and coffee
foods that create discomfort. (including decaffeinated) can precipitate
dyspepsia.
4. Encouraged verbalizations of feelings  This can reduce anxiety and fear thereby
and thoughts reducing the perception of pain and discomfort

Collaborative:

5. Provided and implemented prescribed  Client may receive nothing by mouth (NPO)
dietary modifications. initially.

E At the end of 2- 3 hours of nursing interventions, the pt. was able to verbalize relief of pain and
demonstrate relax body posture.

3.

S Binhud akong tiil ug dili kayo ko kalakaw ug layo.

- Weak in appearance
O - Bedrest
- Decreased performance
- Pallor

A Fatigue related to poor physical condition

 P At the end of 6- 7hours of nursing interventions, the pt. will be able to improve condition and
participate in desired activities.

E At the end of 6- 7 hours of nursing interventions, the pt. was able to improve condition and
participate in desired activities.

4.

S Binhud akong tiil ug dili kayo ko kalakaw ug layo.

- Weak in appearance
O - Bedrest
- Decreased performance
- With O2 inhalation

A Impared Gas Exchange related to reduced RBC

P At the end of 2 days of nursing interventions, the pt. will be able to demonstrate improved
ventilation/oxygenation with clear breath sounds

E At the end of 6- 7 hours of nursing interventions, the pt. was able to improve condition and
participate in desired activities.