Sample Nursing Care Plan

Cues | Nursing diagnosis | Rationale | Objective | Nursing Intervention | Rationale | Evaluation |

Subjective>“Mabilis ang aking paghinga” as verbalized by the patient.Objective>- shortness of breath- lethargy- tachycardia-finger clubbing- audible expiratory wheezing sound- with mechanical ventilatorVS taken as follows:BP- 120/80PR- 125RR- 30Temp – 37.4Diagnostic evaluation:ABG levels;PaO2 – 75pH – 7.33CO2 – 47 | Impaired gas exchange related to ventilation perfusion imbalance as evidenced by: SOB, lethargy, tachycardia, finger clubbing, audible expiratory wheezing sound, using mechanical ventilator, decreased level of PaO2, pH and increased level of CO2 | Entry of noxious agent↓Release of mediators↓Abnormal inflammation of the lungs↓Chronic inflammation↓Scar tissues formation↓Narrowing of airway lumen↓Airflow limitations↓Impaired gas exchange↓wheezes | After 6-7 hours of nursing intervention, the client will demonstrate improved ventilation and adequate oxygenation of tissues by ABGs within client’s normal limits and absence of symptoms of respiratory distress | Independent:- Assess the frequency / depth and ease of breathing

- Assess mental status- Monitor respiratory rate, depth, and effort; ascertain cause of hyperventilation- Monitor for carbon dioxide narcosis (change in level in O2, CO2, blood gas level, decreased RR, headaches)- Monitor and graph serial ABGs and pulse oximetry readings

- Elevate the head and thrust frequently change position, breathe deeply and cough effectively- Encourage adequate rest and limit activities to within client tolerance.- Encourage client and SO to stop smoking and attend cessation programs as necessaryDependent:- Administer medications as indicated (e.g., corticosteroids, antibiotics, bronchodilators, expectorants)Collaborative:- Give oxygen therapy correctly | - The manifestation of respiratory distress depends on the indication of the degree of lung involvement and general health status-Nervousness,...