Diagnosis: ------ ASSESSMENT DIAGNOSIS RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION S: Meron syang ubot sipon, ilang araw na. As verbalized by th mother of the patient.
Ineffective Airway Clearance Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway.
After 8 hours of nursing intervention, airway clearance patency will be maintained, secretions will be readily expectorated and there will be signs of reduction in congestion. Vital signs taken and recorded.
Assisted in Semi- fowlers position.
Encouraged breathing exercises.
Administered prescribed medications.
Provided supplemental humidification via use of nebulizer. This is for baseline comparison.
Proper positioning help in draining secretions. This will promote proper lung expansion.
Prescribed meds such as bronchodilators helps in aiding effective airway clearance. Nebulization helps in liquefying secretion for better and faster expectorating the secretions.
After 8 hours of nursing the patient will maintain airway patency and reduction of congestion. NURSING CARE PLAN Name of the Patient: Mr. R. J. C Diagnosis: DFS ASSESSMENT DIAGNOSIS RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION S: Pwede na dapat sya umuwi, kaso tuaas naman an bp nya. As verbalized by themother of the patient.
O: Altered Blood Pressure (Increase) 8:00 am: 140/80 9:00 am: 110/70 12:00 nn: 130/80 Ineffective Peripheral Tissue Perfusion related to vasoconstriction of blood vessels. Increased cardiac output that injures the endothelial cells of the arteries and the action of prostaglandins. Vasoconstriction occurs and blood pressure increases. After 8 hours of nursing intervention the patient blood pressure will decrease from 140/80 to 120/70 mmHg. Monitored blood pressure.
Instructed to have enough rest.
Instructed to eat low fat and low salt diet.
Administered anti - hypertensive drug as ordered.
This is for baseline comparison.
Sodium tends to be excreted at a faster rate.
To prevent edema that may activate renin angiotensin aldosterone system.
To control BP and to avoid other complications.
After 8 hours of nursing intervention the patients blood pressure was decreased from 140/80 to 120/70 mmHg.
NURSING CARE PLAN Name of the Patient: Mr. N. B. M Diagnosis: DHF ASSESSMENT DIAGNOSIS RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION