Nursing Care Plan

Problem: cough and colds (bronchopneumonia)

Assessment Explanation of the Goals and objectives Nursing intervention rationale evaluation
problem
Date: May 14, Goal: After a day of Dx:
2009 Nursing interventions, the
client will be able to
S: Mother “..wala maintain airway patency.
naman na syang
lagnat, yung ubo Objectives:
saka sipon na
lang niya ang 1) After 2 hours of
problema.” nursing
:”..inuubo siya intervention, the
pero wala naming client will be able
plema” 2) After 2 hours of
:Father: “Ang nursing
nagging sakit lang intervention, the
naman niya nun client will be able to
eh sipon kao demonstrate
pabalik balik.” reduction of
congestion with
clear breath sounds
O: respiration 1)
rate: 52 per
minute
Quick, shallow
breaths with
occasional deep
breaths
Irregular
Crackles
cough

Dx: Ineffective
airway clearance
related to airway
spasms
 Nursing Care Plan

Problem: acute gastroenteritis

Assessment Explanation of the Goals and objectives Nursing intervention rationale evaluation
problem
S; “..nagtatae Goal: Dx Goal fully met if client
siya pero di After an 8 hour shift of : Observe and record frequency, : gives significant was able to evacuate
naman gaanong nursing interventions, characteristics, amount, time of day, information data about well formed stools
malala..” the client will be able to and precipitating factors related to the advance of the
:”..sabi nung reestablish normal occurrence of diarrhea. condtion or effectiveness
doctor kanina eh pattern of bowel :Auscultate abdomen for bowel of interventions
hindi raw functioning. sounds : to maintain hydration
masyadong
maganada yung Objectives: :Monitor intake and output :to maintain skin
tae kanina niya After 1 hour of nursing integrity: skin breakdown
kasi green yung intervention, the client Tx: Assist as needed with pericare can occur quickly when
kulay,,” will be able to have after each bowel movement. diarrhea occurs
bowel sounds within the : Provide diaper change and gentle : to promote comfort of
O: twice bowel normal range, clansing. the client
movement during : provide dry linen as necessary. :to maintain hydration
my shift After 2 hours of nursing
: loose liquid , imtervention, the client : regulate IVF within the ordered
yellowish , non will have decreased flowrate. :to maintain hydration
foul smelling, non frequency of bowel of and provide nutrition
luminous feces bowel movement, at Edx: Encourage mother to continue needs of the client
least twice ady or once breastfeeding.
Dx: Diarrhea for every shift.
related to
inflammation of After 3 hours of nursing
gastrointestinal intervention, the client
tract. wiil be able to evacuate
well formed stools.