Nursing Care Plan

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DATE| CUES| NURSING DIAGNOSIS| KNOWLEDGE BACKGROUND| GOAL| NURSING INTERVENTION| RATIONALE| EVALUATION| | Subjective:“Medyo masakit ang dibdib ko pag umuubo ako.”as verbalized by the patientObjective:Productive coughYellow sputum dischargedPain scale of 10/10| Acute pain R/T coughing | Acute pain is described as an unpleasant sensory or emotional experience associated with actual or potential tissue damage or described in terms of such damage ;sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months.| After 8 hrs of nursing interventions, the patient will be able to have a decreased sensation of pain every time he coughs| Monitor vital signsEstablish rapport with the patientInstruct patient to do deep breathing exercises and assist in splinting techniques during coughing episodes Promote comfort measures like backrub.Encourage diversional activities such as TV/radio.Force fluids to at least 2000ml per day and offer warm, rather than cold water. | -To establish baseline data -To gain trust and to promote patient’s cooperation.-Deep breathing facilitates maximum expansion of the lungs and splinting reduces chest discomfort and promote forceful cough effort -To promote nonpharmacological pain management-To distract attention and reduce pain. -Fluids especially warm water aids in mobilization and expectorations of secretions. | After 8 hrs of nursing interventions, the patient sensation of pain every time he coughs has decreased|

DATE| CUES| NURSING DIAGNOSIS| KNOWLEDGE BACKGROUND| GOAL| NURSING INTERVENTION| RATIONALE| EVALUATION| | Subjective:“masakit sa dibdib kapag umuubo,lumulunok at gumagalaw” as verbalized by the patient.Objective:Initial VSBp: 80/60PR: 89RR: 21T: 37.5 * There’s a pain at the left upper abdomen. * Restlesness| * Ineffective airway clearance r/t excessive mucus.| * Inability to clear secretions or obstruction for the...
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