NURSING CARE PLAN #1

Date Time Days of confinement Days of contact

August 16, 2010 07:30 am Day 1 First day of contact

Assessment Nursing Diagnosis Planning Nursing Intervention Rationale Evaluation

SHORT TERM GOAL
Subjective data: “Ineffective Breathing SHORT TERM 1. Monitor vital signs. 1. To have baseline Goal Partially Met
“Nahihirapan po ako Pattern related to GOAL: data & for comparison. At the end of nursing
huminga.” as verbalized severe pain as After 4 hours of 2. Check capillary refill 2. To determine blood intervention the
by the patient. evidenced by dyspnea nursing intervention and conjunctiva for circulation. patient was not able
secondary to presence the patient will be able paleness. to display Effective
Objective data: of chest thoracostomy to display a effective 3. Elevated head of bed 3.To promote breathing pattern but
v/s: tube.” breathing (semi-fowler’s position) physiological/ patient show absence
RR-46cpm pattern as evidenced Psychological ease of of cyanosis.
PR-84bpm by absence of maximal inspiration.
BP-90/60mmhg cyanosis 4.Encouraged 4. to promote breathing
T-36C position of comfort . pattern.
 Use of accessory 5. Encouraged
muscle to breathe slower/deeper respirations
 Tachypnea by using of pursed-lip
 w/ stab wound technique, deep breathing
laceration 5cm in left exercises, splinting
posterior axillary technique
 w/ chest tube
thoracotomy in left DEPENDENT:
posterior axillary in 1. Administer O2 at 3-4 1. For management of
450cc level. liters per minute as underlying pulmonary
 Pallor ordered by the physician. condition.
 w/ capillary refill of
2. Administer analgesics 2. To inhibits
4sec.
(Ketorolac 30mg TIV) as prostaglandin synthesis
 pale palpebral
ordered by the physician. by decreasing the
conjunctiva
activity of the
cyclooxygenase
enzyme.
NURSING CARE PLAN #2
Date Time Days of confinement Days of contact
August 16, 2010 07:30 am Day 1 First day of contact

Assessment Nursing Diagnosis Planning Nursing Intervention Rationale Evaluation

Subjective: “Deficient fluid volume SHORT TERM GOAL 1. Monitor vital signs 1. To have a baseline SHORT TERM GOAL
No cues related to active fluid After 8 hours of data & to determine Goal Partially Met
volume loss (CTT nursing intervention alteration of vital signs At the end of nursing
Objective: drainage).” the patient will be able to its normal values. intervention the
v/s to maintain fluid patient was not able
RR-46cpm volume at a functional 2. Provide safety 2. To prevent injury to display stable vital
PR-84bpm level as evidenced by measures when client is sign, good skin turgor
BP-90/60mmhg adequate urinary confused.(side rails up) but with adequate
T-36C output , stable vital urine output, prompt
 Pallor sign, good skin turgor 3. Note change in mental 3.These signs indicate capillary refill and
 Dry and poor skin and prompt capillary status/behavior. sufficient dehydration to show no signs of
turgor refill and show no (confusion, lethargy, cause poor cerebral shock.
 w/ capillary refill of signs of shock dizziness) perfusion or electrolyte
4sec. imbalance.
 decrease urine
output DEPENDENT:
 w/ Chest 1. Administer IVF D5LR 1. Steady rehydration
thoracostomy tube in 1L at 31-32gtts/min as over time prevents
left posterior axillary ordered by the physician. peaks/valleys in fluid
in 700cc level level.
NURSING CARE PLAN #3
Date Time Days of confinement Days of contact
August 16, 2010 08:00 am Day 1 First day of contact

Assessment Nursing Diagnosis Planning Nursing Intervention Rationale Evaluation

Subjective: Acute Pain related to SHORT TERM GOAL 1. Monitor vital signs. 1. To have baseline
“Sumasakit po ung dibdib actual tissue damage After 4 hours of data & to determine SHORT TERM GOAL
ko.” as verbalized by the resulting from inserted nursing intervention alteration of vital signs
patient. foreign object(chest the patient will be able to its normal values. Goal Met
 w/ pain scale of 8/10 thoracostomy tube).” to verbalize pain is 2. Accept client’s 2. To know the At the end of nursing
decreased from 8/10 description of pain and description of pain. intervention the
to 3/10. convey acceptance of patient was able to
Objective: client’s response to pain. verbalize pain is
v/s decreased from 8/10
RR-46cpm 3. Provide comfort 3. To promote non- to 3/10
PR-84bpm measures (touch, nurse’s pharmacological pain
BP-90/60mmhg presence) quiet management.
T-36C environment, calm
 w/ guarding behavior activities.
 w/ irritability
 w/ facial grimace 4. Encouraged use of 4.To distract attention
relaxation technique such and reduce tension.
as deep breathing.

DEPENDENT: DEPENDENT:
1. Administer analgesics 1. To maintain
(Ketorolac 30mg TIV) as acceptable level of pain.
ordered by the physician. Notify physician if
to maximum dosage as regimen is inadequate
needed, to meet pain control
goal.

NURSING CARE PLAN #4

 Date Time Days of confinement Days of contact
August 16, 2010 07:30 am Day 1 First day of contact

Assessment Nursing Diagnosis Planning Nursing Intervention Rationale Evaluation

Subjective: “Impaired Physical SHORT TERM GOAL 1. Repositioned the 1. To prevent pressure
“Nung pagdating naming mobility related to After 8 hours of patient every 2 hours. ulcer. SHORT TERM GOAL
dito nun nanghihina na severe pain secondary nursing intervention Goal Met.
nga siya, ngayon ganyan to presence of chest relatives of the patient 2. Supported affected 2. To maintain position At the end of nursing
na siya hirap na siya thoracostomy tube.” will verbalize body parts with pillows or function and reduce intervention the
makagalaw” understanding of risk of pressure ulcers. patient relatives
As verbalized by the situation and verbalized
patients friend. individual treatment 3. Provided safety 3. To prevent fall that understanding of
regimen and safety measures like use of side may cause injury. situation and
Objectives: measures. rails. individual treatment
 w/ Chest regimen and safety
thoracostomy tube 4. Provided passive range 4. For good circulation. measures.
in left posterior of motion.
axillary in 700cc
level of drainage 5. Note 5. To assess functional
 w/ stab wound emotional/behavioral ability.
laceration 5cm in left response to problems of
posterior axillary immobility.

6. Encouraged 6. Enhances self-

participation in self care. concept and sense of
independence.
DEPENDENT:
1.Administer medication 1.To permit maximal
prior to activity as needed effort.
by pain relief.

NURSING CARE PLAN #5

 Date Time Days of confinement Days of contact
August 16, 2010 07:30 am Day 1 First day of contact

Assessment Nursing Diagnosis Planning Nursing Intervention Rationale Evaluation

Subjective: “Impaired Tissue LONG TERM GOAL 1. Inspect wounds for 1. Promotes timely LONG
No cues Integrity related to After 3 days of nursing every shifts to note intervention and TERM GOAL
mechanical factor (stab intervention, The for any changes. revision of plan of care Goal Partially Met
Objectives: wound on left posterior patient will At the end of nursing
2. Encouraged optimum
v/s: axillary, chest be able to display nutrition w/ high 2. To optimize healing intervention the
RR-46cpm thoracostomy tube).” progressive quality protein, potential patient was not able
PR-84bpm improvement in wound sufficient calories and to display progress in
BP-90/60mmhg healing, show vitamins wound healing but
T-36C absence of show absence of
 w/ stab wound hemorrhage and signs 3. Encouraged 3.To limit metabolic hemorrhage and
adequate periods of
laceration 5cm in left of infection. demands, maximize signs of infection.
rest and sleep.
posterior axillary energy available for
 w/ wound dressing healing, and meet
dry and intact comfort needs.

 w/ Chest 4. Practice aseptic 4.Reduce risk of cross-

thoracostomy tube in technique for contamination.
cleansing
left posterior axillary
/dressing/medicating
in 700cc level. the wound.

5. Discuss importance 5.Promotes early

of early detection and intervention/reduces
reporting of changes potential for
or any unusual complications.
physical
discomfort/changes
in pain
characteristics.
Dependent:

Administer antibiotics To Relief pain,

(Mefenamic Acid 800mg) Headache, fever and
as ordered by the soft tissue injury.
physician.
NURSING CARE PLAN #6
Date Time Days of confinement Days of contact
August 16, 2010 07:30 am Day 1 First day of contact

Assessment Nursing Diagnosis Planning Nursing Intervention Rationale Evaluation

Subjective: “Risk for Infection After 2 hours of 1.Encouraged proper 1. A first line defense Goal Met
no cues related to invasive nursing hand hygiene by all against health care After the nursing
caregivers .
procedures such as intervention the associated infections intervention the
Objective:
insertion of foreign patient’s relative will (HAI) patient’s relatives
 w/ stab wound at
object(chest gain verbalize infection
left posterior axillary
thoracostomy tube).” knowledge in 2.Stress the necessity of 2. Premature control and discuss
 w/ Chest taking antivirals/antibiotics
infection control discontinuation of wound care.
thoracostomy tube in as indicated
as evidenced by treatment when client
left posterior axillary
discussing the begins to feel well may
in 700cc level.
wound care. result in return of
infection and potentiate
drug resistant strains.
DEPENDENT:

1. Change the wound 1.To eliminate infection.

dressing as ordered by
the physician. Observe
aseptic technique.

2.Administer anti-infective 2.to Inhibits enzymes

(Co-amoxiclav) as involved in formation of
ordered. peptidoglycan layer of
bacterial cell wall.