Ncp3 Cunanan

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Name: Abigael P.

Cunanan Group: N42-VI


Date: 10-10-22 CI: Mrs. Myrna de Chavez Fesalboni, RN

NURSING CARE PLAN 3


Name of Client: Patient S
Age/Sex: 62 y/o – Female

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective data: Ineffective Short-term: Independent Short-term:


breathing
“Naglisod na sya og pattern related Within 1 hour of 1. Assess breath sounds and 1. Monitor for changes in lung After 1 hour of
ginhawa ma'am to anxiety as nursing other vital signs. sounds, respiratory rate and nursing intervention, the
pagsulod ninyo, kay evidenced by intervention, the depth, and oxygen saturation patient was able to:
nakaputi man gud mo verbalization of patient will be able closely for worsening or
tanan nya nakuyawan feeling of to: improvement. - Indicated
siya ba mao na naglisod tension. verbally feeling
run og ginhawa." As - Indicates, 2. Instruct patient to perform 2. To promote deep inspiration, of comfortability
verbalized by the either deep breaths. which increases oxygenation. when breathing
caregiver. verbally or as evidenced by
through V/S O2 at 90%.
Objective data: behavior, 3. Monitor for anxiety or change 3. Feeling short of breath can
feeling in mental status. induce panic which can, in turn, GOAL MET.
• Tachypnea comfortable worsen hyperventilation.
• Restlessness and when Long-term:
anxiety breathing. 4. Monitor oxygen saturation 4. Pulse oximetry is a helpful
• Hyperventilation continuously using pulse tool to detect alterations in After 3 days of nursing
• Nasal flaring Long-term: oximetry. oxygenation initially; but, for intervention, the patient
• Chills CO2 levels, end-tidal CO2 was able to:
• V/S: Within 3 days of monitoring or arterial blood
RR: 30 bpm nursing gases (ABGs) would require - Carries out
O2: 90% intervention, the obtaining. ADLs, breathing
patient will be able pattern remains
to: 5. Assist the patient sitting up in 5. An upright position allows normal.
a semi-Fowler’s or high- for a better lung expansion,
- Carries out Fowler’s position. hence more air reaching the
ADLs, lungs for gas exchange. October 10, 2022
breathing 2:30 PM
pattern
remains 6. Provide emotional support 6. A supportive environment
normal. during episodes of respiratory can reduce anxiety and oxygen
distress. demand. It reduces respiration
and therefore slows fatiguing.

7. Instructed patient to avoid 7. To prevent increase oxygen A.CUNANAN,FSUU/SN


unnecessary action. demand.

8. Keep necessary 8. To prevent strenuous activity


materials/things within the that may increase oxygen
patient’s reach. demand.

Dependent

9.Administer O2 and 9. Oxygen administration


paracetamol for fever as corrects hypoxemia.
prescribed.

Collaborative

10. Teach the family and 10. In case of an emergency,


caregiver signs and symptoms the family needs to have the
of respiratory distress. skills to provide initial care and
call for help to prevent care
delays and ensure the best
possible patient outcome.

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