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    Nursing Care Plan

    Uploaded by

    Mikkee Villaruel

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    © All Rights Reserved
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    Nursing Care Plan

    Uploaded by

    Mikkee Villaruel
    15 views2 pages

    Copyright

    © © All Rights Reserved

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    DOCX, PDF, TXT or read online from Scribd

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    Copyright:

    © All Rights Reserved
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    Download as docx, pdf, or txt
    15 views2 pages

    Nursing Care Plan

    Uploaded by

    Mikkee Villaruel

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    NCM 100 NURSING CARE PLAN 04/21/2016

    Goal/Objective of
    Cues/Clues Nursing Diagnosis Scientific Rationale Interventions Rationale Evaluation
    Care
     Subjective:  "Sleepless  Long term:  Independent: Fully Met:
    Verbalized Nights" After 1 week 1. Recommende  Desired to
    that he has  Sleep of nursing d a nap 1) Sleep is sleep.
    been deprivation care, patient without needed to
    experiencing must be able waking feel
    sleepless to have a episodes. refreshed
    nights for the Sleep deprivation is regular 2. Assess and
    last 3 days. the condition of not sleeping client's sleep restored.
     Objective: T- having enough pattern. patterns and 2) Usual sleep
    39°C; PR- sleep. It is caused by  Short term: usual bedtime
    his fever that has patterns are
    108/min; RR- After 8 hours rituals and
    been going on for 5 individual.
    20; BP-120/80 of nursing incorporate
    days and bouts of these into the 3) Difficulty in
    care, patient
    productive cough must be able plan of care. sleeping can
    with whitish mucoid to recover 3. Observ be a side
    secretions, moderate from e effect of
    in amount. It insomnia client's medications
    suppresses immune and may be medica ; caffeine
    system function. It able to take tion, also
    can cause fatigue, naps without diet, interferes
    daytime sleepiness, waking and with sleep.
    clumsiness and episodes. caffein 4) Clients have
    weight loss or weight e or reported
    gain. It affects the fluid that
    brain and cognitive intake. uncomforta
    function. 4. Position client ble position
    comfortably
    is a
    for sleep.
    common
    factor of
    sleep
    disturbance.

    Cues/Clues Nursing Diagnosis Scientific Rationale Goal/Objective of Interventions Rationale Evaluation


    Care
     Subjective:  Ineffective  Long term:  Independent: Fully Met:
    Productive airway After 1 week 1. Increase
    cough with clearance f nursing intake of 1) Fluids help Partially Met:
    whitish mucoid care, the fluids. minimize  Desired to
    secretions, client will be 2. Small drying and sleep.
    moderate in relieved from frequent maximize  Body
    amount. An ineffective airway cough and feedings. ciliary malaise
    clearance is the
     Objective: T- other action to  Able to eat
    inability to clear symptoms.
    39°C; PR- 20-30% of
    secretions or  Dependent move
    108/min; RR-  Short term: lunch
    obstructions from the 3. Bisolvon secretions.
    20; BP-120/80 After 1-2 reserved
    respiratory to syrup, 1 tbsp 2) Increase
     Physical hours of
    maintain airway TID appetite /
    Examination: nursing care, Not Met:
    patency. It is caused  Interdependen desire to
    teary eyes, cough will  (+) rales
    by the productive t/ eat.
    flushed face, expel, RR
    cough with whitish 3) Treat
    skin warm to will return to Collaborative
    mucoid secretions, productive
    touch, (+) normal 4. Brought to
    moderate in amount.
    rales, (-) (<20), fever the X-ray chesty
    Pneumonia,
    wheezes will be Department coughs
    bronchitis, COPD,
    <37.5°C, (-) for chest X- where the
    asthma, PTB, lung
    rates on ray (AP chest is
    cancer, radial neck
    ascultatory view) congested
    surgery, mechanical
    ventilatory with
    assistance, seizures, mucus that
    disc surgery, is difficult
    thyroidectomy, to cough
    laryngectomy, up.
    lyphomas, burns and 4) X-ray is a
    chemical irritants test that
    could overtax the helps
    mechanisms for physicians
    ineffective airway diagnose
    clearance. and treat
    medical
    conditions
    regarding
    the
    airways.

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