Angeles University Foundation

College of Nursing
NURSING CARE PLAN
Name of the patient: VICTORIA, ROSENDO Date: APRIL 30, 2010
Diagnosis: PNEUMOHEMOTHORAX W/ MULTIPLE RIB FRACTURE NCP # 1
Age: 54 Sex: MALE
NURSING EXPECTED
ASSESSMENT SCIENTIFIC EXPLANATION OBJECTIVES NURSING INTERVENTIONS RATIONALE
DIAGNOSIS OUTCOME
>esta
S> “sumasakit ang Acute pain r/t Nociceptors are free Short term: blish rapport. > to gain pt’s. and Short term:
dibdib ko lalo na inflammation nerve endings that are After 4º of NI, S.O.’s trust. After 4º of NI,
kapag gumagalaw” as of tissues in widely distributed the pt’s. rate >asses pt’s. general >to note for the pt’s. rate of
verbalized by the pt. the chest area throughout the body. of pain will condition. additional pain decreased
AEB an Chemically mediated decrease from abnormalities and for from 6/10 to
O> the pt. manifested inserted chest activation of nociceptors 6/10 to 3/10. further evaluation of 3/10.
the ff: tube can be initiated by cell it.
-knife like stabbing thoracotomy. wall destruction as a Long term: >monitor and record VS. Long term:
pain on the ches area result of events such as After 3 days of After 3 days of
upon movement w/ a tissue injury or NI, the pt. will >auscultate breath sounds. > to obtain baseline NI, the pt.
pain rating scale of inflammation. Since demonstrate data for comparison. demonstrated
6/10. there is tissue injury nonpharmacol >to note for other nonpharmacolo
-dry skin within the CTT site, ogic methods respiratory symptoms gic methods
-weakness. activation of chemicals that provide >provide safety measures. such as that provide
-paleness of such as bradykinin, relief of pain. rales/crackles, relief of pain.
mucous membranes. prostaglandin, wheezes, etc.
>for promotion of
relaxation and may
enhance coping
abilities by refocusing
attention.

Student Nurse: BONDOC, ERNESTO JR. P. MA. THERESA B.

SERRANO, R.N., M.A.N.
 BSN III – 5; Grp. 20 Clinical
NURSING EXPECTED
ASSESSMENT SCIENTIFIC EXPLANATION OBJECTIVES NURSING INTERVENTIONS RATIONALE
DIAGNOSIS OUTCOME

-chest retractions Substance P,histamine, >to reduce body’s

>encourage adequate rest
-restlessness serotonin, leukotrienes consumption of oxygen
periods.
-irritablility and nerve growth and gain
-VS: T=37ºC; factor are released. additionalstrenght.
P= 91bpm; R= With the release of
>provide information about
30cpm these chemicals, pain > for maximum lung
proper positioning like high
BP=100/70mmHg is produced due to the expansion.
back rest.
action of theses
The pt. may chemical mediators. >to keep the pt.
>encourage pt. to increase
manifest: hydrated and to
oral fluid intake.
-cyanosis strengthen the immune
-body malaise system.
-respiratory arrest
>assess for patency of CTT.
-generalized >so that proper
infection. drainage of fluids from
-other respiratory the lungs to the draining
complications. bottle is achieved.
>provide proper ventilation >to promote ventilation
such as opening of windows, and proper breathing as
changing of soiled linens & well as relaxation.
removing of unnecessary
materials in the bed. >to prevent respiratory
>encourage turning, coughing complications.
and deep breathing exercises.
> for efficacy of nursing
> attend needs. care and easy coping of
pt.

Instructor