NURSING CARE PLAN

ASESSMENT NURSING SCIENTIFIC PLANNING INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS RATIONALE
Acute Pain related Production of Long Term: Independent: Long Term:
to congestion of mucous
Subjective: After of 2 weeks of • Monitor pain • To have a After of 2 weeks of
lungs secondary to nursing scale of the baseline data nursing
“Sumasakit ang asthma as interventions the client interventions the
ang tagiliran,” as evidenced by pain client will be able client was able
verbalized scale of 6/10 Congestion of reduced pain by reduced pain by
Objective: lungs 7/10 to 3/10. • Demonstrate 7/10 to 3/10.
• It enhance
non-
Short Term: client’s comfort Short Term:
pharmalogical
• cramping pain After 2 hours of and relaxation After 2 hours of
management
• pain scale of Epithelial damage nursing nursing
- Music
6/10 interventions the interventions the
Therapy
client will be able client was able to:
• tenderness of to: - Massage
RUQ
Pain • Encourage • It can irritate the
• restlessness • Verbalized non
patient to avoid stomach by
• Verbalized non phamalogical
alcoholic increasing HCL
• moaning Reference: phamalogical activities injury
beverages and
• grimace Harrison’s Principle activities injury
cigarettes of • Demonstrate at
of internal • Demonstrate at coffee least 3 lifestyle
Medicine least 3 lifestyle • To prevent changes
• Encourage
changes further fatigue.
adequate rest
period
• Demonstrate • To promote
comfortable comfortable
positions position
-Sim’s positions

• Instruct the • to prevent

client to further asthma
reduced stress

Collaborative
• Instruct client
to consult • Modification
nutritionist for from the diet
meal planning may prevent
 NURSING CARE PLAN
ASESSMENT NURSING SCIENTIFIC PLANNING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS RATIONALE
ineffective Altered lung Long Term: Independent: Long Term:
Breathing Pattern defense
Subjective: related to smoking After of 2 weeks of • Maintain calm • To limit level of After of 2 weeks of
nursing attitude of the anxiety nursing
“Nahihirapan nga as evidenced of interventions the client interventions the
ako minsan,” as RR of 26cpm client will be able client was able
verbalized -deceased cough have normal have normal
Objective: effectiveness respiratory pattern • Instruct respiratory pattern
• To promote lung
-decreased of 16-20 client to expansion of 16-20
mucocilliary Short Term: perform deep Short Term:
• RR: 26 breathing
function
After 2 hours of exercises After 2 hours of
• asymmetrical -altered mucus nursing nursing
chest • It can promote
interventions the interventions the
expansion lung expansion
client will be able • demonstrate client was able to:
• presence of Impaired gas to: diaphragmatic and breathing of
cough exchange breathing the client.
• Verbalized 3
• crackles sound • Verbalized 3 -lie in supine causative
upon Increase close causative position, inhale factors
auscultation volume factors and exhale
slowly • Cigarettes are • Demonstrate at
• Demonstrate at main cause why least 3
least 3 • Encourage client the client has techniques for
Irregular breathing
techniques for to reduce or DOB. It coping
pattern
coping avoid used of decreases the behaviors
behaviors cigarettes cilliary action of
the lungs.
Ref: Medical
Surgical page 626

• To promote
breathing pattern
• Encourage
exercise • To provide
information and
• Provide health to encourage
teachings about client to avoid
the ff: taking cigarettes
-smoking: cause
and effect