August 3, 2017 | Author: Princess Andrea Bulatao | Category: Respiratory System, Clinical Medicine, Medical Specialties, Respiration, Diseases And Disorders
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Bulatao, Princess Andrea S. BSN IV Group B2 Unciano College – Sta. Mesa NURSING CARE PLAN Actual Problem: Activity Intolerance Cues and Data Subjective: 

Nursing Diagnosis

Goal of Care

Activity intolerance

After 8 hours of nursing

“Hinihingal ako

related to

interventions, the patient

kahit wala akong

imbalance between

will demonstrate a

ginagawa at minsan

oxygen supply and

decrease in

nahihirapan akong

demand as

physiological signs of

huminga”, as

evidenced by

intolerance and will

verbalized by the

reports of fatigue,

promote good


weakness and

respiratory function.

exertional dyspnea. Objectives:  With oxygen support  Pale  Restless



Obtain vital signs of the patient. Rationale: Health status is regulated through homeostatic mechanisms. A change in vital signs might indicate a health change.

After 8 hours of nursing

intervention, the patient has demonstrated a decrease in physiological signs of intolerance and was able to promote good respiratory

Observe for respiratory rate and rhythm, presence of nasal flaring and use of accessory muscles when breathing like the diaphragm and coastal muscles.


 Emaciated  Poor muscle tone

Rationale: Nasal flaring and use of accessory muscles indicates increased effort is required for breathing.  Place the patient in semi fowler’s position. Rationale: To increase chest expansion and alleviate dyspnea. Increase fluid intake. Rationale: To prevent dehydration. 

Engage in activities of daily living base on capabilities. Rationale: To avoid overexertion and to reduce fatigue. 

Encourage to maintain good personal hygiene.

Rationale: To promote comfort and prevent infection. Give foods that are rich in protein and carbohydrates. Rationale: For energy and to build up muscles.

Enhance familial support. Rationale: To relieve patient’s anxiety and to assist the patient with all the things that he/she needs. 

Rainier A. Santos

BSN-IV Group-B2 Unciano College, Sta.Mesa NURSING CARE PLAN Impaired Gas Exchange Cues and Data Subjective: “medyo

Nursing Diagnosis  Impaired gas

Goal of Care After 2 hours of nursing

Interventions/Rationale Evaluation Assess causative and After 2 hours of nursing

nahihirapan ako

exchange related to

intervention, the patient

contributing factors

intervention the patient

huminga” as verbalized


will demonstrate

Rationale: helps in

was able to demonstrate

by the client


improved ventilation and identifying plan of care

improved ventilation and


imbalance as

decreased symptoms of

decreased symptoms of

 Pale

evidenced by

respiratory distress.

 Restlessness


depth, use of accessory

 Nasal flaring

Respiratory rate,


 Respiratory rate

restlessness, nasal

Rationale: Nasal flaring

flaring and

and use of accessory


muscles indicates

34cpm  Dyspnea  Asthma

Note respiratory rate,

increased effort is required for breathing.

Elevate head part of the bed (semi fowlers to

respiratory distress.

high fowlers position). Rationale: improves airway and lung expansion. Encourage deep breathing and coughing exercises Rationale: promotes optimal chest expansion and drainage of secretions Encourage adequate rest and limit activities to within client tolerance Rationale: helps limit oxygen consumption. Keep environment allergen free. Rationale: to reduce

irritant effect of dust and chemicals in airways. Emphasize the importance of proper nutrition. Rationale: helps improve stamina and may reduce difficulty in breathing.

Encourage to maintain good personal hygiene.

Rationale: To promote comfort and to prevent further infection.

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