NURSING CARE PLAN Patients name: Mark Anthony Escobido Sex: Male Age: 19 years old Ward: Medicine

Ward

Status: Mark Anthony Escobido, a 19 years old patient, has been admitted to the medicine ward with chief complaint of sudden difficulty of breathing and chest pain. He was diagnosed with Community Acquired Pneumonia and possible pleural effusion. He is currently on oxygen via facemask @ 8-9L/min tolerated, with ongoing PNSS 1L x 12 o via IV @ 83-84gtts/min located at left arm, infusing well. Diet as tolerated with strict aspiration precaution. Vital signs are taken every 4 hours and recorded. Upon assessment, the patient shows difficulty of breathing as evidenced by increase respiratory rate and chest excursion. Lung crackles are present upon auscultation by the student nurse. Attending Physicians orders: Cefuroxime 750mg through IV q8o Mefenamic acid 500 mg PO q8o Paracetamol 500mg PO PRN Assessment Subjective: > Chief complain: Sudden difficulty of breathing and chest pain as verbalized by the patient Objective: > VS taken as follows: BP: 90/60 mmHG PR: 110 bpm RR: 49 rpm Temp: 37.2oC > altered chest excursion > > (+) crackles Nursing Diagnosis > Ineffective breathing pattern related to decrease lung expansion as evidenced by difficulty of breathing Inference Warm moistened air is inhaled and passes into the lung Inspired air contains particulates that are removed by mucus present in the bronchial tubes Filling of the bronchi with thick mucus Contraction of surrounding muscles to propel mucus upward Bronchospams Narrowed airway Dyspnea or Goal After 8 hours of nursing intervention the patient will have a decrease in difficulty of breathing. Planning > Establish rapport with the patients mother > Closely monitor vital signs Rationale > To gain the patients trust and cooperation > To be able to assess the severity of the condition/disease process > To maintain well infusion > To promote dilation of the bronchial tubes > To continue proper care at home > To facilitate movement of secretions > To be able to observe the client closely > To maintain optimal wellness Nursing Interventions > Established rapport with the patient > Assessed for the patients vital signs every four hours(Temp: 37.4oC PR: 110 Bpm, RR: 50 rpm) > Regulated IV infusion at 37-38 gtts/min > Performed nebulization every 4 hours > Educated the mother on home-use of nebulizer > Performed chest physiotherapy > Kept the patient comfortable > Provided evening care prior to bedtime sleep Evaluation > After 8 hours of nursing intervention the patient was able to : - have an improved breathing pattern - show normal ranges of vital signs - facilitate movement of secretions

> Closely regulate IV medication infusion > Perform nebulization > Educated the mother on home-use of nebulizer > Perform chest physiotherapy > Place the client in a comfortable position. > Ensure adequate sleep and rest

Prepared By: SANTOS Angelique N.

labored respiration

Prepared By: SANTOS Angelique N.