Nursing Care Plan

Client: Bartolabac, Fidela Hospital No.: 0-800-22500-773

Age: 66 years old Room No.: C414

Impression: cough, dyspnea Physician: Dr. R. Go

Diagnosis: Community acquired pneumonia – high risk in acute respiratory failure Nurse’s

Signature: R.C.R. UCSN

Clinical Portrait Pertinent Data

Assessment

Upon assessment patient X, 66 years old, a

Roman Catholic from 0671 Sitio Anagan, Apas, Cebu

City, was seen lying on bed conscious and a febrile

with the S.O. at the bedside. Patient had an IVF of

D5NSS infused at right arm/hand running at 30

gtts/min + dopamine at 10gtts/min. A NGT was

inserted and was aided with a mechanical ventilator.

History of Present Illness

A case of Mrs. Fidela B. Bartolabac, 66 years

old, born on April 24, 1942 at Berida, Leyte,

Roman Catholic and is widowed for 3 years,

residing at 0671 Sitio Amagan, Apas, Cebu City

6000 was admitted on November 29, 2008 at 1:44

pm at Chong Hua Hospital.

Mrs. Bartolabac has Bronchial Asthma taking

91

Pulse oximeter was connected at the right hand and

FBC-UB was noted.

Significant Findings

Patient was tachypniec with vital sighs of BP=

90/60 mm/Hg. HR of 117 bpm and RR of 31 cpm.

Roles positive at binasal assessment and occasional

wheeze BLF. Patient was tachycardic with regular

murmurs. Positive cyanosis on finger nail beds of

both hands. With history of PTB.

Nursing Review of Systems Gordon's 11 Functional

Health Patterns

1. Health perception/ Health management

Patient had history of Pneumonia and

Pulmonary Tuberculosis. Doctors prescribed her with

medicines but the patient was not able to maintain it

Seretide and Ventolin inhaler for treatment but is

poorly compliant. She was taking vitamins. Family

history of diabetes.

Mrs. Bartolabac used to for about 30 packs

per year and drinks alcohol occasionally. She was

positive of pulmonary tuberculosis and was poorly

taking anti TB medications for 2 years. Months

prior to admission weight loss was positive and

occasional chest pains noted

Chief Complaints

Cough, dyspnea

Vital Signs Taken Upon Admission

T= 36.2◦C R= 31 cpm

P= 117 bpm BP= 90/60 mmHg

92

due to financial problem. She never complained

about her condition though she experienced short of

breathe and cough. Her family decided to admit her

to Chong Hua hospital when she cannot tolerate it

anymore and when cyanosis was observed by the

family member.

She used Wachichao plant for her

maintenance.

2. Nutrition/ Metabolic

Patient is choosy about her food. She usually

eats rice and liver barbeque. She loves to eat fruits

as long as they have. She seldom eats meat. She

eats vegetables once in a while. In the morning, she

eats bread and ate breakfast and lunch (brunch) at

around 11:00AM

Few weeks before admission, she just want to

Laboratory results

X-Ray

12/14/08

Conclusion

1. Chronic inflammation process in both lung fields

2. Modified silhouette

3. Atherosclerosis of the thoracic aorta

4. Calcified trachoebronchial tree

5. Generalized osteopenia/osteoporosis

CBC

12/13/08

93

eat porridge for her meal. Now, she has Nasogastric

tube attached.

3. Elimination

Patient had normal elimination pattern but

then, few days after her admission, she experienced

constipation but had good urine output. Now, she

defecates daily and maintain good urine output.

4. Activity/ Exercise

Patient usually does sedentary activities at

home, like eating, watching television, talking with

some friends, and sometimes does sweeping.

On first contact with the patient, seen patient

lying on bed, weak, and with limited movements.

Eight days after admission, patient had great

Result reference unit

WBC 6.28 4.8-10.8

10^3/ul

RBC 5.45 4.2-5.4 10^0/ul

HGB 16.5 12-16 g/dl

HCT 50.6 37-47 %

MCV 92.8 81.99 fl

MCH 30.3 27-31 pg

MCHC 32.6 33-37 g/dl

Plt 193 130-140 10^3/ul

Result reference unit

Neutrophil % 72 40-74 %

Lymphocyte % 1707 19-48 %

Monocyte 9.9 3.4-9 %

Eosinophil .2 0-7 %

Basophil .2 0-1.5 %

Neutrophil # 4.53 1.9-8 10^3/ul

Lymphocyte # 1.11 1.9-8 10^3\ul

94

improvement, she can now smile, do sign language,

move her extremities and with glow on her face.

Though she still needs assistance, she can turn to

sides now with ease.

5. Cognitive/ Perceptual

Patient needs to be oriented with the time and

date though she is aware that she is currently

admitted in the hospital. She is responsive (through

gestures), coherent, and can relate to conversations.

She even smile with jokes and wave her hands when

someone she used to see visited her. She speaks in a

very low voice at present because the Endotracheal

tube was just removed.

6. Sleep/Rest Patterns

Patient usually sleeps between 8:00PM –

9:00PM and wakes up around 5:00AM. She had

afternoon nap everyday.

Monocyte .62 .16-1 10^3/ul

Eusinophil .01 0-.8 10^3/ul

Basophil .01 0-.2 10^3/ul

RDW 14 11-16 %

PDW 9.8 9-14 %

MPV 9.5 7.2-11.1 fl

Ionized calcium .75 1.09-1.33 mmol/L

Na 121.9 135-148 mmol/L

K 4.25 3.5-5.0 mmol/L

Temperature 36.6 C

Thb 15.0 g/dl

FIO2 21 %

pH 7.287 7.35-7.45

pCo2 68 35-45 mmHg

PO2 54.5 >80 mmHg

HCO3 31.8 mmHg

95

Now that she is admitted, she could hardly

sleep because of her condition. Her vital signs need

to be monitored hourly. She is also disturbed by her

cough.

7. Self Perception/ Self Concept

Though the patient looses weight, she doesn’t

look under weight at all. She is just weak because

she is sick. She looks accommodating and friendly

despite of her condition.

8. Role/ Relationship

Patient lives in her own house with her

daughter and two grandchildren. They have close

family ties. She is open to them with her feelings. She

is fond of talking. She spends most of her time at

home with her family.    

+CO2 33.9 mmHg

SO2 84.4 95-98 %

U/A

12/13/08

Physical Characteristics

Color dark yellow

Transparency sly cloudy

pH 6.0 5-6

Sp-gray1.030 1.003-1.005 random

Chemical Characteristics

Result reference unit

Protein 100 - mg/dl

Glucose - - mg/dl

Ketone - - mg/dl

Urobilinogen normal up to 2

mg/dl

Leukocyte - - WBC/ul

96

9. Sexuality/ Reproductive Health

The patient has five children, two boys

(deceased) and three girls. Her husband died long

time ago.

10. Coping/ stress tolerance

The patient is open to her family about her

problems. But then, with regards to her sickness, she

never complained about it. She kept it to herself as

long as she can tolerate it.

11. Values and beliefs

Patient is a Roman Catholic but didn’t go to

church. She didn’t join any religious community.

Bld - - mg/dl

Bilirubin - - mg/dl

Nitrite - -

mg/dl

Vit C 40 * mg/dl

Microscopic

RBC 2 2-18 /ul

WBC 8 6.14 /ul

Bacteria Mucus none * /ul

Hyaline cast 10 * /ul

Glucose Fasting 149 60-110 mg/dl

Cholesterol 165 150.0-240.0

mg/dl

Triglycerides 109 45.0-150.0

mg/dl

VLDL 21.8 .0-40.0 mg/dl

97

Nursing Problems

1.) Ineffective airway clearance

2.) Impaired physical mobility

3.)Risk for aspiration

4.)Risk for impaired skin integrity

5.) Impaired verbal communication

Nursing Diagnosis

1. Ineffective Airway Clearance related to increased

sputum production as evidenced by cough.

2. Impaired Physical Mobility related to restrictive

devices

3. Impaired Verbal communication r/t attachment to

mechanical ventilator.

4. Risk for infection related to depressed immune

system

5. Risk for aspiration r/t tube feedings and

LDL 115.6 .0 150.0 mg/dl

HDL 27.6 30.0-9.0 mg/dl

Temperature 36 C

FIO2 14.2 g/dl

pCO2 21.0 %

pH 7.335 7.35-7.45

PO2 60.4 35-45 mmHg

HCO3 238.1 780 mmol/L

+CO2 33.7 mmol/L

BE 3.8 mmol/L

SO2 99.8 95-98 %

Acid fast stain

Specimen – sputum

Report: no acid fast bacilli seen

98

secretions.

Nursing Care Plan

Cues Nursing

Diagnosis

Scientific

Basis

Goal and

Outcome

Criteria

Nursing Actions Rationale Evaluation

S: “Giubo ug

kutasan ako

mama ug

maglisod

Actual

Ineffectiv

e Airway

A cough is

a protective

reflex that

cleanses

After 8

hours of

nursing

interventio

To perform nursing

care to help patient

improved Airway

Goal

Partially

met

99

siya ug

ginhawa” As

verbalized

by the

clients

daughter.

O:

1.Received

patient lying

on bed,

conscious,

coherent

afebrile,

tachypneic

and with

mechanical

ventilator

support.

Clearance

related to

increased

sputum

productio

n as

evidence

d by

cough.

the lower

airways by

an

explosive

expiration.

Inhaled

particles,

accumulate

d mucus,

inflammatio

n or

presence of

a foreign

body

initiates the

reflex by

stimulating

the irritant

receptors in

the airway.

n, client’s

airway is

free of

secretions

as

evidenced

by eupnea

and clear

lung

sounds

after

coughing

or

suctioning.

Specifically

:

1. Client

will

Independent;

1. Assess respiratory

movements and

use of accessory

muscles.

2. Assess cough for

effectiveness and

productivity.

Use of

accessory

muscles to

breathe

indicates an

abnormal

increase in

work of

breathing.

(Gulanickl et.

al.: 2007,480).

Patients may

have

ineffective

cough due to

fatigue or thick

tenacious

After 8

hours of

nursing

interventio

n, client’s

airway was

free of

secretions

as

evidenced

by eupnea

and clear

lung

sounds

after

coughing or

suctioning.

Specifically

100

2. Change in

respiratory

status.

3. Patient

demonstrat

e persistent

coughing

and

dyspnea

4. Abnormal

lung sounds

5. With

pulse

oximeter

attached

The cough

consists of

inspiration,

closure of

glottis, and

vocal cord,

contraction

of glottis,

causing

sudden,

forceful

expiration

that

removes

the

offending

matter. The

effectivene

ss of the

cough

maintain a

stable

breathing.

2. Client’s

mucus will

be thin

and scant.

3. Client’s

breath

sounds are

clear.

3. Observe sputum

color, amount,

and odor and

report significant

changes.

Dependent:

1. Monitor pulse

oximeter and

ABGs.

secretions.

(Gulanickl et.

al.: 2007,480).

A sign of

infection is

discolored

sputum. An

odor may be

present.

(Gulanickl et.

al.: 2007,480).

Hypoxemia

may result

from impaired

gas exchange

:

1. Client

maintaine

d a stable

breathing.

2. Client’s

mucus

wasthin

and scant.

101

- T=

36.2oC

- P= 81

bpm

- R= MV

- BP=

90/55

mmHg

.

depends on

the depth

of the

inspiration

and the

degree to

which the

airway

narrow,

increasing

the velocity

of the

expiratory

gas flow.

Cough

occurs

frequently

in healthy

individuals.

2. Monitor chest x-

ray reports.

Collaborative:

from build up

of secretions.

ABGs provide

data about

carbon dioxide

levels in the

blood.

(Gulanickl et.

al.: 2007,480).

These

determine

progression of

disease

process.

(Gulanickl et.

al.: 2007,480).

102

A persistent

cough

indicates

presence of

disorder or

a disease.

An acute

non

productive

cough often

indicates

bronchitis

or viral

pneumonia.

A persistent

cough is

commonly

caused by a

tumor,

1. Consult the

respiratory

therapist for

chest

physiotherapy

and nebulizer

treatments, as

appropriate and

ordered.

Chest

physiotherapy

includes the

techniques of

postural

drainage and

chest

percussion to

loosen and

mobilize

secretions in

smaller

airways that

cannot be

removed by

coughing or

suctioning. A

nebulizer may

103

congestion,

or

hypertensiv

e airways.

A cough

that

produces

purulent

sputum

usually

indicates

infection,

whereas a

cough that

produces

non

purulent

sputum is

non specific

and merely

2. Assist with

bronchoscopy and

thoracentesis, as

appropriate.

be used to

humidify the

airway to thin

secretions to

facilitate their

removal.

(Gulanickl et.

al.: 2007,481).

Bronchoscopy

is done to

obtain lavage

samples for

culture and

sensitivity and

to remove

mucous plugs;

thoracentesis

is done to

drain

104

indicates

irritation.

(McCance,

2000:1150

3. Anticipate

possible need for

intubation if

patient’s

condition

deteriorates.

4. Administer

medications such as

antibiotics and

associated

pleural

effusions.

(Gulanickl et.

al.: 2007,481).

Intubation may

be needed to

facilitate deep

suctioning

efforts and to

provide source

for

augmenting

oxygenation.

(Gulanickl et.

al.: 2007,481).

A variety of

medications

105

expectorants for

productive coughs.

Administe r inhaled

bronchodilators and

inhaled steroids, as

prescribed, to open

airway and decrease

inflammation.

are available

to treat

specific

problems.

(Gulanickl et.

al.: 2007,481).

Nursing Care Plan

Cues Nursing

Diagnosi

Scientific Basis Goal and

Outcome

Nursing

Actions

Rationale Evaluatio

n

106

s Criteria

S- Patient

pointing

her throat.

-no

verbalizatio

ns

O- • NGT

inserted

•Mechanic

al

ventilator

noted

•Suction

machine at

bedside.

•patient

pointing on

Potential

Risk for

aspiratio

n r/t

tube

feedings

and

secretion

s.

Crackles indicate

static pulmonary

secretions that

need to be

mobilized. This

also includes

accumulation of

saliva on the

airways .When

this obstructs the

airway the

pulmonary tissues

beyond the

collapses and

massive

atelectasis

results.

(Smeltzer,Bare,,Hi

After 8

hours of

nursing

interventi

on the

patient

will be

able to

maintain

a patent

airway

Specificall

y the

patient

and s.o.

will be

able to:

To perform

nursing care

to prevent

aspiration

Independent

:

1. Monitor

level of

consciousne

ss.

2. Auscultate

bowel

A decreased level

of consciousness is

a prime factor for

aspiration

(

Gulanick/Mayers:20

08

pp18)

• Decreased

gastrointestinal

goal met:

After 8

hours of

nursing

interventi

on the

patient

was able

to

maintain

a patent

airway.

Specificall

y the

patient

and s.o.

107

her neck. nkle

cheever;2008,534

)

Pulmonary

complications

from NGT

intubation occur

because coughing

and cleaning of

the pharynx is

impaired ,

because gas build

up can irritate the

phrenic nerve and

because

tubes may

dislodged,

retracting the

distal and above

the

1. Feel

relief with

concerns

of

secretions

2. Will be

able to do

basic

suctioning

procedure

s.

3. Have a

secured

NGT

placemen

t.

sounds to

evaluate

bowel

motility and

assess for

abdominal

distention

and

firmness.

3. Position

patient in an

elevated

upper body

or side lying.

mobility increases

the risk of

aspiration because

foods and fluids

accumulate in the

stomach(Gulanick/

Mayers:2008;pp19

• This decreases

the risk of

aspiration by

promoting the

drainage and

secretions away

from the airway.

(Gulanick/Mayers:2

008

pp.19)

•Reduces oro-

was able

to:

1. Feel

relief of

concerns

about

secretions

.

2. Able to

do basic

suctioning

procedure

s.

3. Have a

secured

NGT

placemen

t

4.Have no

108

esophagogastric

sphincter places

the patient of risk

for aspiration

(Smeltzer,Bare,Hi

nkle,

Cheever;

2008,1180-1181)

4. Have

no

abnormal

breath

sounds

upon

assessme

nt.

5. Have

normal

breathing

pattern.

4. In Patients

with artificial

airways.

• Perform

oral

suctioning as

needed.

5. In

patients with

NGT

• Check

placement of

tube before

feeding by

color or

pharyngeal

secretions and

reduces aspiration

rising.

((Gulanick/Mayers:

2008

pp.19)

•A placed tube

may erroneously

deliver tube

feeding into the

airway.

((Gulanick/Mayers:

2008

pp.19)

abnormal

breathe

sounds

upon

assessme

nt

5. Have a

normal

breathing

pattern.

109

aspirate or

listening for

bubbling

sounds upon

air induction.

Collaborative

:

6.Collaborat

e with

respiratory

therapist, as

needed to

determine

cuff

pressure(tub

es)

7.

•On ineffective or

over inflated cuff

can increase the

risk for aspiration.

((Gulanick/Mayers:

2008

pp.19)

• Appropriate

mixture of food as

well as balanced

110

Collaborate

with the

dietitians

about having

blenderized

diet for the

patient.

Dependent:

8. Suction

hourly as

ordered by

the

physician.

9.

Administer

drugs in

meal provides

nutrients needed.

((Gulanick/Mayers:

2008

pp.63)

•To eliminate

secretions

(Doenges 63)

• Drugs in tablet

forms must be

crushed during

administration

(Doenges 63)

111

appropriate

preparation

as ordered

by the

physician.

112

Nursing Care Plan

Cues Nursing

Diagnosi

s

Scientific

Basis

Goal and

Outcome

Criteria

Nursing

Actions

Rationale Evaluation

S: Patient

wrote on

a piece of

paper

“gusto na

ko

mulakaw”

O:

1.Receive

d patient

lying on

bed,

Actual

Impaired

Physical

Mobility

related

to

restrictiv

e

devices

In place

mechanic

al devices

are

common

to non

ambulator

y patients

but in

cases

where

patients

are able

After 8 hours of

nursing

intervention

the patient will

be relieved

from

discomfort

Specifically

1. Patient will

be free of

complications

To perform

nursing care

to help

patient

exercise in

bed

1. Assess

patient’s

ability to

perform ADL’s

effectively

and safely on

>Restricted

movement

affects the

ability to

perform most

ADL’s .

Goal met

After 8 hours of

nursing

intervention the

patient was

relieved from

discomfort

Specifically

1. Patient was

free of

113

conscious,

coherent

afebrile,

tachypnei

c and

with

mechanic

al

ventilator

support.

2. Pulse

oximeter

at right

hand

3. IVF

infused at

right hand

to walk,

the

devices

would

likely limit

their

activities

provided

that

machines

are easily

altered by

movemen

t

examples

would be

casts,

neck

support

and

of immobility,

as evidenced

by intact skin,

absence of

thrombophlebit

is, & normal

bowel pattern.

2. Patient will

perform

exercises in

bed

3. Patient will

move allowed

body parts for

exercise.

a daily basis.

2 Assess

ability to

perform ROM

to all joints.

3 Encourage

& facilitate

early

ambulation &

other ADL’s

when possible

.

4 Provide

positive

reinforcement

>This provides

baseline

measurement

for the future

evaluation and

guides therapy.

>The sooner

the patients

becomes

mobile, less

chance that

debilitation will

occur.

>Patients may

be reluctant to

move or initiate

new activity

complications

of immobility,

as evidenced

by intact skin,

absence of

thrombophlebiti

s, & normal

bowel pattern.

2. Patient was

able to perform

exercises in

bed

3. Patient

moved allowed

body parts for

exercise.

114

4. Weak

muscles

ventilator.

(Microsoft

® Encarta

® 2007)

during

activity.

5 Evaluate

patient’s

performance

in doing

ADL’s.

due to fear of

falling. A

positive

approach allows

the learner to

feel good about

learning

accomplishmen

ts.

> Evaluating

performance

helps in

improving once

abilities &

maximizing

activities.

Even patients

who are

temporarily

115

6 Assess

patient or

caregiver’s

knowledge of

immobility &

its

complication.

immobile are at

risk for effects

of immobility

such as skin

breakdown,

muscle

weakness,

thrombophlebiti

s, constipation,

pneumonia, &

depression.

> Regular

examination of

skin (especially

over bony

prominences)

will allow for

prevention or

early

116

7 Assess skin

integrity

8 Assess

elimination

pattern.

9 Turn &

position the

patient every

2 hours or as

recognition &

treatment of

pressure sores.

> Turning the

patients

optimizes

circulation to all

tissues &

relieves

pressure.

> Immobility

promotes

constipation

> It helps in

evaluating

patient’s

outcome from

117

needed.

10 Evaluate

the patient

free of

complications

of immobility.

11 Assess

patient’s

difficulty in

walking.

12 Encourage

walking

exercise

interspersed

with rest

nursing

interventions.

> It helps in

determining

factors that

contributed to

patient’s

difficulty in

moving

> To reduce

fatigue.

> To enhance

safety for client

& SO/

118

periods

13 Involve

client/ SO in

care, assisting

them to learn

ways of

managing

deficits.

14 Instruct

client/ SO in

safety

measures as

individually.

(eg.

maintaining

safe travel

pathway,

proper

caregivers.

> To reduce

risk of falls

> It helps in

determining

patient’s

outcome to be

effective or not.

119

lightning.

120