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NURSING CARE PLAN

Identified Problem: presence of mucus secretions


Nursing Diagnosis: Infection related to inadequate secondary defenses as evidenced by presence of respiratory mucus secretions
CUES
Subjective:
Gahapon ky ga lisod siya ug
ginhawa pero karon ky ge ubo
na siya unya nay plema as
verbalized by the patients SO

Objective:
Laboratory Results:
Hgb-86g/l
Hct-0.26
Neutrophil-0.46
-nasal flaring
-DOB
-irritable

OBJECTIVES

Short term objectives:


After 8 hours of duty
patient will be able to
identify interventions to
prevent/reduce risk of
infection

Long term objectives:


After 3 days of duty
patient will be able to
achieve timely wound
healing, be free from
respiratory infection.

INTERVENTIONS
1. Monitor vital signs every 4 hours
2. Monitor intake and output
3. Encourage breastfeeding every 2 our
and as necessary
4. Cradle patient as desired comfort
5. Assist on giving patients mediations
6. Provide therapeutic environment

RATIONALE
1. To have a baseline data and for
subsequent evaluation
2. To monitor for fluid and
electrolytes imbalance
3. To prevent malnutrition and to
maintain metabolic demands
4. To provide comfort
5. To reduce risk of infection and
possible complications
6. Altered environment may
contribute to the exacerbation
of patients condition

EVALUATION
Short term:
After 8 hours of duty was able to
identify some intervention to
reduce infection. Goal was
partially met.

Long term:
After 3 days patient was not able
to achieve timely wound healing.
Goal was not met.