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NCP PCAP C

The nursing care plan involves 3 patients. Patient 1 has persistent coughing and dyspnea with abnormal lung sounds. The goal is to clear the airway within 8 hours and have effective clearance within 4 days. Patient 2 is on oxygen and IV therapy with the goals of preventing complications of immobility within 8 hours and being able to perform normal activities without removing equipment within 4 days. Patient 3 produces yellowish-green sputum, with the goals of preventing infection within 8 hours and remaining afebrile without signs of infection within 4 days.

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Rio Bonifacio
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9K views4 pages

NCP PCAP C

The nursing care plan involves 3 patients. Patient 1 has persistent coughing and dyspnea with abnormal lung sounds. The goal is to clear the airway within 8 hours and have effective clearance within 4 days. Patient 2 is on oxygen and IV therapy with the goals of preventing complications of immobility within 8 hours and being able to perform normal activities without removing equipment within 4 days. Patient 3 produces yellowish-green sputum, with the goals of preventing infection within 8 hours and remaining afebrile without signs of infection within 4 days.

Uploaded by

Rio Bonifacio
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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II.

NURSING CARE PLAN No. 1

Assessment
Subjective:
May halak pa sya
at may plema pa rin
pag ubo nya as
verbalized by the
clients mother.
Objective:
-patient
demonstrates
persistent coughing
and dyspnea
-presence
abnormal
sounds
v/s
T=
P=
R=

of
lung

Nursing
Diagnosis
Ineffective
clearance
increased
producton.

Planning

airway Short term goal:


due
to
After 8 hours of
sputum
nursing
intervention, the
clients airway
will be free of
secretions
as
evidenced
by
eupnea and clear
lung sounds after
coughing.

Intervention
Independent
-Assess vital signs

Rationale

Evaluation
Short term goal:
GOAL
PARTIALLY
MET

-To provide baseline data.

-assess
respiratory -use of accessory muscle indicates an
movements and use of abnormal increase in work of
accessory muscles.
breathing.
-assess sputum color, -a sign of infection is discoloured
amount, and odor and sputum. An odor may be present.
report
Long term goal:
GOAL
-teach mother chest -for better excretion of sputum
PARTIALLY
physiotherapy
METMET

Long term goal:


After 4 days of
nursing
Dependent
intervention, the Administer medications -to
treat
disease
client will be as ordered,
complications.
able to have
effective airway
clearance and no
sputum
productions with
normal
lung
sounds

and

other

NURSING CARE PLAN No. 3


Assessment
Subjective:
Objective:
-presence
yellowish
sputum

Nursing
Diagnosis

Planning

Risk for infection Short term goal:


related to impaired
After 8 hours of
immune system
nursing
intervention, the
of
client will have
green
no further signs
of infection and
will
remain
afebrile.

Intervention

Rationale

Independent
-monitor vital signs

-to provide baseline data

- assess sputum

-to
monitor
treatmeant

effectiveness

Evaluation
Short term goal:
.
GOAL
PARTIALLY
of MET

- teach clients mother -to facilitate better excretion of


chest physiotherapy
sputum.
Short term goal:
Long term goal:
.
- After 4 days of nursing
GOAL
intervention, the client
PARTIALLY
will remain afebrile and
MET
display no further signs
of infection.
Dependent
Take medicines as -to treat existing disease
prescribed

NURSING CARE PLAN No. 2


Assessment

Nursing
Diagnosis

Subjective:
Impaired physical
mobility related to
restrictive devices,

Objective:
-patient has O2
inhalation via nasal
canula
-with ongoing IVF
connected to left
arm

Planning
Short term goal:
- After 8 hours of
nursing intervention, the
client will be free of
complications
of
immobility as evidenced
by intact skin and
normal
bowel
movement.

Intervention

Rationale

Independent
- Instruct mother teach and
remind child not to remove
O2 inhalation

-to still facilitate breathing and


proper IV therapy

- Change position frequently

-to avoid pressure sores

Evaluation
Short term goal:
GOAL MET

Long term goal:


GOAL MET
-Keep linens wrinkle-free.

Long term goal:


-After 4 days of nursing
intervention, the client -assess illumination pattern
will be able to perform
normal
activities
without trying to remove
O2 inhalation or IVF.
.

- Reduces dermal irritation and


risk of skin breakdown.
-immobility promotes
constipation

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