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    Capitol University: Name: Sophia B. Duquinlay Date: 09-16-21 Section/ CN: 137 NCP #: 1

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    Sophia Duquinlay
    This nursing care plan addresses a patient experiencing drowsiness, irritability, difficulty sleeping and breathing, high blood pressure, low body temperature, and slow heart rate. The plan involves changing the patient's sleeping position, using a CPAP machine, following a dietary plan to lose weight, elevating the legs, and monitoring vital signs. The goals are to relieve pain and breathing issues within a few days, return to normal sleep and work within a week to 10 days, and lose over 20 pounds in a month. The evaluation notes the patient's symptoms improved and he was discharged after maintaining normal vital signs and sleep without assistance for 5 days.

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    Capitol University: Name: Sophia B. Duquinlay Date: 09-16-21 Section/ CN: 137 NCP #: 1

    Uploaded by

    Sophia Duquinlay
    29 views2 pages
    This nursing care plan addresses a patient experiencing drowsiness, irritability, difficulty sleeping and breathing, high blood pressure, low body temperature, and slow heart rate. The plan involves changing the patient's sleeping position, using a CPAP machine, following a dietary plan to lose weight, elevating the legs, and monitoring vital signs. The goals are to relieve pain and breathing issues within a few days, return to normal sleep and work within a week to 10 days, and lose over 20 pounds in a month. The evaluation notes the patient's symptoms improved and he was discharged after maintaining normal vital signs and sleep without assistance for 5 days.

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    This nursing care plan addresses a patient experiencing drowsiness, irritability, difficulty sleeping and breathing, high blood pressure, low body temperature, and slow heart rate. The plan involves changing the patient's sleeping position, using a CPAP machine, following a dietary plan to lose weight, elevating the legs, and monitoring vital signs. The goals are to relieve pain and breathing issues within a few days, return to normal sleep and work within a week to 10 days, and lose over 20 pounds in a month. The evaluation notes the patient's symptoms improved and he was discharged after maintaining normal vital signs and sleep without assistance for 5 days.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    29 views2 pages

    Capitol University: Name: Sophia B. Duquinlay Date: 09-16-21 Section/ CN: 137 NCP #: 1

    Uploaded by

    Sophia Duquinlay
    This nursing care plan addresses a patient experiencing drowsiness, irritability, difficulty sleeping and breathing, high blood pressure, low body temperature, and slow heart rate. The plan involves changing the patient's sleeping position, using a CPAP machine, following a dietary plan to lose weight, elevating the legs, and monitoring vital signs. The goals are to relieve pain and breathing issues within a few days, return to normal sleep and work within a week to 10 days, and lose over 20 pounds in a month. The evaluation notes the patient's symptoms improved and he was discharged after maintaining normal vital signs and sleep without assistance for 5 days.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    CAPITOL UNIVERSITY

    College of Nursing
    Cagayan de Oro City
    Name: Sophia B. Duquinlay Date: 09-16-21
    Section/ CN: 137 NCP #: 1

    NURSING CARE PLAN

    SUBJECTIVE OBJECTIVE
    ● ”experiencing drowsiness ● dry mouth
    every morning when I’m at ● swelling legs
    work” verbalizes by the ● BP: 180/100 mmHg
    patient ● HR: 30 beats/ min.
    ● RR: 16 breaths/ min.
    ● irritable most of the time ● Temperature: 24 degrees celsius
    ● Pain scale: 7/10
    ASSESSMENT
    ● “I woke up in the middle of ● Body weight: 223 lbs.
    the night because he snores
    too loud.” verbalizes by the
    wife

    ● “he woke me up one morning


    gasping for air”-verbalized by
    the wife
    ● Difficulty in daily functioning
    ● Difficulty in maintaining sleep state
    DIAGNOSIS ● Ineffective airway clearance
    (P&E/P.E.S ● hypertension
    FORMAT) ● hypothermia
    ● bradycardia

    SHORT TERM LONG TERM


    ● Pain relief after 1 hour pain ● The patient will be able to verbalize
    scale would be 4/10 sleeping well at night after 5 days since
    ● The patient can maintain sleep admission
    after 5 hours ● The patient will be able to go back to work
    PLANNING
    ● Normal vital signs after 10 after 10 days
    (Goals and
    hours ● The patient will be able to maintain sleep
    Objective)
    ● The patient can breathe without the help of any apparatuses (CPAP,
    normally after 10 minutes BiPAP, oxygen) after a week
    ● The patient will lose at least 22.3 lbs. after
    month

    INTERVENTION RATIONALE
    ● change the sleeping position of ● to keep the throat open during sleep.
    the patient, sleeping on the
    side rather than the back with
    special pillows supporting the
    Intervention
    back. (independent)
    (With
    ● administer CPAP therapy ● prevents airway closure while in use.
    Rationale)
    (dependent)
    ● dietary plan with help of the ● losing as little as 10 percent of body weight
    dietician (collaborative) can reduce the number of times a person
    with obstructive sleep apnea.

    MEDICAL-SURGICAL NURSING NCM 112

    NURSING CARE PLAN (NCP) FORMAT Professor: Emman M. Parangue, R.N.


    ● Elevate the patient’s leg above
    his heart (independent) ● to reduce swelling
    ● check vital signs every 30
    minutes
    ● to monitor and to make sure the patient is
    (independent) showing progress.
    The patient maintained normal vital signs and sleep without experiencing difficulty breathing
    without using any use of apparatuses after 5 days. The dietary plan was effective because he
    lost at least 25 lbs within a month and the swelling of his legs subsided. And will be
    discharged today.
    EVALUATION

    MEDICAL-SURGICAL NURSING NCM 112

    NURSING CARE PLAN (NCP) FORMAT Professor: Emman M. Parangue, R.N.

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