St.

Anthony’s College
San Jose, Antique
Nursing Department
NAME:A.T.A
AGE:82 years old
Dr.: O.C.C
CC: Cough for 2 weeks NURSING CARE PLAN
CUES NURSING RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE: Activity intolerance Coughing is the body's Activity intolerance INDEPENDENT: Establishes patient’s After 4 hours of nursing
“Hindi ako katurog tungod related to way of removing related to exhaustion •Evaluate patient’s capabilities or needs interventions, the patient was
sa akon ubo.” as verbalized exhaustion foreign material or associated with response to activity. and facilitates choice of able to demonstrate measurable
by the patient. associated with mucous from the interruption in usual •Provide a quiet interventions increase intolerance inactivity
interruption in lungs and throat. The sleep pattern because environment and limit •Reduces stress and with absence of dyspnea and
usual sleep pattern two general of discomfort, excessive visitors during acute excess stimulation, excessive fatigue.
because of classifications of coughing and yspnea. phase. promoting rest.
discomfort, cough are productive •Elevate head and •These measures
excessive coughing coughs(producing encourage frequent promotes maximal
and dyspnea. phlegm or mucous position changes, deep inspiration, enhance
OBJECTIVE: from the lungs)and breathing and effective expectoration of
V/S taken as follows: non-productive coughing. secretions to improve
BP- 120/80 coughs(dry and not •Encourage adequate ventilation.
T- 36.6 producing any mucous rest balanced with •Facilitates healing
P- 99 or phlegm). moderate activity. process and enhances
R-26 Promote adequate natural resistance.
nutritional intake.

DEPENDENT:
Administer medications
as prescribe: mucolytic or
expectorants.
 St. Anthony’s College
San Jose, Antique
Nursing Department
NAME:A.T.A.
AGE:82 years old
Dr.: O.C.C
CC: Cough for 2 weeks NURSING CARE PLAN
CUES NURSING DIAGNOSIS RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Impaired breathing patternrelated Presence of semi After 2-4hours INDEPENDENT: To facilitate After 2-4hours
“Nabudlayan ako to presence of semi- thick discharges, of nursinginterventionthe 1. Placed the client lungexpansion. of Nursingintervention the
maginhawa.” as thick nasaldischarges. obstruction tothe client willdemonstrate insemi- clientdemonstrated
verbalized by the nares, impaired enhance breathing pattern. fowlersusing pillo To decrease the enhanced breathing pattern.
patient. Breathing pattern. ws. viscosity of the
2. Encouragedto discharges.
increasefluidintak
e. Citrus fruits
OBJECTIVE: 3. Advised totake containsvitamin C
V/s taken as citrus fruits. that boosts
follows: theimmune system.
BP-120/80
T-36.3
P- 98
R- 29
 St. Anthony’s College
San Jose, Antique
Nursing Department
NAME:A.T.A.
AGE:82 years old
Dr.: O.C.C
CC: Cough for 2 weeks NURSING CARE PLAN
CUES NURSING RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE: Hyperthermia Hypothalamus is the After 30 mins on -Identified underlying -To obtain factors of After 30 mins on effective
“Ginahilanat akon tatay” as related to increase thermoregulation effective nursing factors that may cause increase body nursing interventions the client
verbalized by the daughter metabolic rate. center of a human interventions the client alterations of body temperature. was able to maintain core
of the patient. body presence of was able to maintain temperature. temperature within normal
infection trigger of the core temperature range of 37.5. Goal met latest
fever, called a pyrogen within normal range of temp: 37.1.
release of 37.5. Goal met latest
prostaglandin E2 temp: 38.1
(PGE2). PGE2 then in
OBJECTIVE: turn acts on the
V/s taken as follows: hypothalamus causing
BP-120/80 heat- creating effects
T-38.4 increase heat
P- 98 conservation and
R- 29 production resulting
increase body
temperature or
hyperthermia.
 St. Anthony’s College
San Jose, Antique
Nursing Department
NAME:E.E.Q.
AGE:34 years old
Dr.: C.
CC: Headache with vomiting 3x NURSING CARE PLAN
CUES NURSING RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE: Risk for injury r/t The increase of BP and Short term goal: Assess general status of To determine the The client was free of any sign of
“Galinginuloko daw multiple factors RR will result to At the end of nursing the client. client’s condition that injury.
matumbaako.” as (headache, hypertension which intervention, the client may cause injury.
verbalized by the patient dizziness, limited may affect the client’s will be free from any Assessed mood copping
motion, feeling of lost of balance, in sign of injury. abilities, personality style To determine the level
warm, especially in relation to limitation that may result in of cooperation.
the eye. of movements the Long term goal: carelessness.
client is unable to gain After nursing To determine the causes
his balance and intervention the risk Assess environmental of injury.
protect his self that factor of client from factor that may lead to
OBJECTIVE: leads to possible pain will be lessen. injury. To lessen the risk of
V/s taken as follows: injury. injury, safe environment
BP- 130/80 After nursing Promoted client’s safety and promote client’s
T- 36.4 intervention, the client by: comfortable.
P- 69 will verbalized Monitor vital sign
R- 33 understanding of
individual factors that Provided material for
may contribute of injury prevention.
possibility of injury.
 St. Anthony’s College
San Jose, Antique
Nursing Department
NAME: E.E.Q.
AGE: 34 years old
Dr.: C.
CC: Headache with vomiting 3x NURSING CARE PLAN
CUES NURSING RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE: Risk for prone High blood pressure After 8 hours of nursing Independent: -Provides basis for After 8 hours of nursing
“Galinginuloko daw behaviour related (HBP) or hypertension interventions, the -Define and state the understanding interventions, the patient will
matumbaako.” As to lack of means high pressure patient will verbalized limits of desired BP. elevations of BP, and verbalized understanding of the
verbalized by the patient. knowledge about (tension) in the understanding of the Explain hypertension and clarifies misconceptions disease process and treatment
the disease. arteries. Arteries are disease process and its effect on the heart, and also understanding regimen.
vessels that carry treatment regimen. blood vessels, kidney, that high BP can exist
blood from the and brain. without symptom or
pumping heart to all even when feeling well.
the tissues and organs
OBJECTIVE: of the body. High -Assist the patient in -These risk factors have
V/s taken as follows: blood pressure does identifying modifiable risk been shown to
BP-140/80 not mean excessive factors like diet high in contribute to
T- 6.3 emotional tension, sodium, saturated fats hypertension.
P- 82 although emotional and cholesterol.
R- 21 tension and stress can -Lack of cooperation is
temporarily increase -Reinforce the common reason for
blood presseure. importance of adhering failure of
to treatment regimen antihypertensive
and keeping follow up theraphy.
appointments.