3rd Part NCPDP
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Transcript of 3rd Part NCPDP
B.1 NURSING CARE PLAN
Patient: Ibonalo, Simeon Sabal Hospital no. IP
Age: 80years old Room no. FW-9
Impression/Diagnosis: Pneumonia Physician: Guangko, Amelita S.
Nurse’s Name and Signature: Go, Bevelyn B. N
CLINICAL PORTRAIT PERTINENT DATAAssessment:
Received patient lying on bed, awake, conscious, and afebrile,
with ongoing IVF of PNSS 1L @ 10gtts/min infusing well at his
left arm.
Significant Findings:
Patient was weak, restlessness and expressed his feelings by
holding the person behind him. Noted teary eyes. Rales and
rhonchi heard upon auscultation.
Vital Signs during First Contact:
T- 37.2 degree Celsius
P-83 beats per minute
R-VR
History of present Illness:
A case of Ibonalo, Simeon Sabal , 80 years old, malem Filipino,
Roman Catholic from J. Labra St. Guadalupe Cebu City was
admitted at Visayas Community Medical Center.
5 days prior to admission patient was noted to had hiccup. Patient
was weak. Decrease sensorium and increase dyspnea episode and
was brought by ERUF to VCMC.
Chief Complaint:
Dyspnea
Health History relevant to Present Condition:
Patient was experienced difficulty in breathing sinch he was 67
years old because of that he was hospitalized 3 times. He was a
tobacco user.
Vital signs taken during admission:
BP-130/80 mmHg
NURSING DIAGNOSIS:
1. impaired breathing pattern related to broncocostriction.
2. effective airway clearance related to mucus production
3. risk for injured skin integrity related to prolonged
immobilization.
T- 37.6 degree Celsius
P-83 beats per minute
R-28 cycles per minute
BP-140/90 mmHg
URINALYSIS REPORT
Test Results Normal Basis
Appearance
Color
Odor
pH
Protein
Specific Gravity
Glucose
Casts
Cloudy
Dark yellow
Aromatic
6.0
(+)
1.02d
(-)
None
Clear
Amber
Aromatic
4.6-8.0
(-)
1.005-1.030
(-)
None
HEMATOLOGY SECTION
TEST NAME RESULT UNIT REFERENCE
RANGE
WBC 3.18 L K/uL 4.1-10.9
Segmenters
Lympho
Mono
Eosinophil
Basophils
RBC
Hemoglobin
hematocrit
MCV
MCH
MCHC
RDW-SD
RDW-CV
Platelet
MP
78.40
16.00
4.40
0.30
0.90
4012
11.80L
35.60L
86.40
28.60
33.10
50.90
16.5H
256.00
10.50
%
%
%
%
%
M/uL
g/dl
%
fL
pg
g/dl
fL
%
K/uL
fL
47.0-80.0
130.0-40.0
2.0-11.0
0-5.0
0-2.0
4.5-5.9
13.5-17.5
41.0-53.0
80.0-100.0
23.0-34.0
31.0-36.0
37.0-54.0
11.6-11-4.8
140.0-440.0
0-99.0
CUES/EVIDENCES NURSING DIAGNOSIS
SCIENTIFIC BASIS
GOALS AND OUTCOME CRITERIA
NURSING ACTION AND NURSING ORDERS
RATIONALE EVALUATION
Subjective cues:
“maglisod man ako
papa og ginhawa
day tungod sa iyang
ubo” as verbalized
by the S.O of the
patient.
Objective cues:
Received patient
lying on bed, awake,
afebrile with
ongoing IVF of
PNSS 1L @
10gtts/min.
-Dyspnea
-Adventitious breath
sounds rales and
Ineffective
airway
clearance
related to
presence of
mucus
production.
Inability to
clear
secretions
or
obstruction
from the
respiratory
tract to
maintain a
clear
airway.
(Doenges;
2006;66)
After 8 hrs. of
effective
nursing
intervention
the patient
will be able to
mobilize
airway is free
of secretions.
The Patient
will be able to
1.to
maintain
airway
patency
Independent:
-asses rate/depth of
respiration and chest
movement and
monitor for
respiratory failure
-Suction
-to reduce discomfort of
moving chest wall or
fluid in the lung.
(doenges,6th edition;67)
-to clear airway when
secretions are blocking
Goal not met:
After 8 hours
of nursing
intervention
patients is not
able to
expectorate
secretions and
still has
difficulty in
breathing.
rhonchi
-Restlessness
-Presence of sputum
-wide-eyed
-cyanosis
2. to
mobili
zed
secreti
ons
naso/trachel/oral prn
-Elevate head of the
bed/ change position
every two hours
DEPENDENT
-Administer/
monitor medication
regimen and note
client response.
-regulate the
intravenous fluid as
airway (doenges,6th
edition;67.)
-To decrease pressure in
the diaphragm/
promoting chest
expansion.
(doenges,6th edition;67)
-to determine
effectiveness of
theraphy/ presence of
side effects(doenges,6th
edition;67)
-to promote fast
recovery(doenges,6th
edition;67)
-to promote
relaxation(doenges,6th
3.To assess
changes and
note
complication.
ordered
-give expertorants/
bronchodilatores
COLLABORATIVE
-assist with medical
procedures
-administer
humidified oxygen
-suggest support
group for significant
others.
edition;67)
-to save time & energy.
(doenges,6th edition;67)
-humidity reduces
viscosity of
secretions(doenges,6th
edition;67)
-to assst woth understanding of way to deal with clients. (doenges,6th edition;67
Subjective cues:
“ naglisod akong
papa og ginhawa”
as verbalized by the
S.O of the patient.
Objective cues:
Received patient
lying on bed, awake,
afebrile with
ongoing IVF of
PNSS 1L @
10gtts/min.
-Dyspnea
-hypoxia
-tachycardia
-restlessness
-changes in
mentation
Impaired
breathing
pattern
related to
bronco-
constriction
After 8 hrs. of
effective
nursing
intervention
the patient
will be able
breathe
effectively.
The Patient
will be able to
-Gain
knowledge
about her
condition
Independent:
1. teach patient that
causes difficulty in
breathing
- to gain knowledge
about the causes of
difficulty in
breathing(doenges,6th
edition;104)
Goal not met:
Patient had
still difficulty
in breathing
- Perform
certain
position that
would
promote
effective
breathing
-.administer
supplemental
oxygen by cannula
or mask, as
indicated:
-Review Laboratory
results as indicated
- elevate head of
bed, in upright or
semi-fowler’s
position.
- Encourage client
participation/
responsibility for
deep breathing
- Enhances oxygen
delivery to the lung for
circulatory uptake,
especially in presence of
reduced/altered
ventilation(doenges,6th
edition;104)
- Monitor effectiveness
of respiratory therapy.
(doenges,6th edition;104)
- Stimulates respiratory
function/lung
expansion.doenges,6th
edition;104)
- aids in reexpansion/
maintaining patency of
small airway(doenges,6th
edition;104)
-to have life
style Changes
exercises, use of
adjuncts, and
coughing, as
indicated
-refer to a physician
if dyspneic worsens.
- encourage patient
to minimize
smoking
- instruct patient to
have a follow-up as
indicted
- Refer to social
services for further
counseling
- provides continuity of
care. (doenges,6th
edition;104)
- smoking would
aggreviate difficulty in
breathing(doenges,6th
edition;104
- aids in monitoring and
effects of medications.
(doenges,6th edition;188)
- promote patient’s
cooperation.(doenges,6th
edition;188)
B.2DISCHARGE PLAN
Patient: Ibonalo, Simeon Sabal Hospital no. IP
Age: 80years old Room no. FW-9
Impression/Diagnosis: Pneumonia Physician: Guangko, Amelita S.
Nurse’s Name and Signature: Go, Bevelyn B. UCCN
PATIENT’S OUTCOME CRITERIA NURSING ORDERAs soon as the patient is admitted and
discharged from the medical ward of Visayas
Community Medical Center, the patient will be
able to:
Assessment:
> Assess for the patient’s vital signs.
>Assess for unusual findings.
Planning:
> Plan for a scheduled visits/ consultations.
> monitor vital signs taking every four hours,
notify deviations from baseline that are
indicative of infection:
-increase in temperature
-increase in respiratory rate
> monitor for signs and symptoms.
-dyspnea
-fever
-cyanosis
>Encourage the patient to outpatient visits for
consultations:
> Plan for activities necessary for easy coping
to the disease.
Implementation:
M> Comply with take home medications as
prescribed by the doctor.
E>Provide a conducive environment necessary
for the patient’s condition.
T> Maintain a healthy lifestyle and monitor
health status
H> Be able to practice health promotion and
illness prevention.
O> Have a clinical visit at least once a week
> Encourage patient to ambulate early in the
morning.
> Administer medications as indicated.
>Explain the importance of the effect of
environment towards the recovery of the
patient.
> Monitor intake and output balance.
> Ascertain patient’s knowledge about
postpartum care.
> Encourage the patient to follow a healthy
lifestyle. Make a calendar planner for visits
during her free time.
D> Follow dietary guidelines to enhance
nutritional requirements with special
considerations on financial capacity.
S> Provide support and comfort.
Evaluation:
Be aware of the condition positively
and learn to cope with her new change
in lifestyle.
> Encourage the patient to follow a healthy
eating pattern.
> Explore ways in which significant others can
be supportive and in ways they could help.
> Encourage the patient to comply with the
interventions given and continue with it at
home and be able to follow-up evaluation of
heath status.