COLLEGE OF NURSING

Visca, Baybay City, Leyte, PHILIPPINES

Tel. no.: (053) 563-7226
Email address: nursing@vsu.edu.ph
Website: www.vsu.edu.ph

NURSING CARE PLAN

Care Plan No.: _3_
Patient’s Name: _____________ C.H.______________ Age/Sex: ___4 y.o./Male___ Chief Complaint/s: ”Nag-sige siya og ubo na nay plema,”
as verbalized by the Mother

Outcome Planned Nursing Interventions

Assessment Cues Nursing Diagnosis Evaluation
Identification Nursing Interventions Rationale
Subjective: Goal: Independent: Goal met.
Acute Pain r/t persistent - To relieve pain 1. Assess or monitor 1. Changes in pulse - The patient was
The mother reported coughing a.m.b. verbal and discomfort the vital signs of the rate and blood able to verbalize a
that the patient is reports of pain, RR – 32 patient every 6 hours pressure indicates relief of pain at
experiencing pain cpm, PR – 91 bpm, nasal Desired pain level less than 3
during flaring, dyspnea, interrupted Outcome: to 4 using a rating
hospitalization. sleep secondary to 2. Administer comfort 2. Comfort scale of 0 to 10
interstitial pneumonia and - The patient will measures such as back measures provided after 6 hours of
hyperaeration be able to rubs and other non- with a gentle touch nursing
Objective: verbalize a relief analgesic measures can lessen interventions
of pain at level discomfort and also
RR – 32 cpm Scientific Basis: less than 3 to 4 increase the effects - The patient was
PR – 91 bpm using a rating of analgesics. able to
O2 Sat – 90% Pneumonia is the inflammation scale of 0 to 10 demonstrate
of lung parenchyma or lung after 6 hours of 3. Position the patient 3. It allows the decrease in RR
Nasal Flaring tissue which is associated with nursing into a Fowler’s position diaphragm to move to 16 - 19 CPM
alveoli edema and congestion. interventions downwards and after 6 hours of
Difficulty in In result, this causes chest allow lung expansion nursing
breathing pain and triggers cough. In - The patient will which improves interventions
addition, it is commonly be able to breathing
Cough caused by aspiration of demonstrate - Patient was able
pathogens such as bacteria decrease in RR 4. Assist and instruct 4. Helps in control of to demonstrate a
Interrupted sleep and viruses. Furthermore, the to 16 - 19 CPM the client to do chest- chest discomfort relaxed manner of
discomfort may worsen when after 6 hours of splinting techniques while improving resting after 6
breathing and coughing. nursing when coughing occurs effectiveness of hours of nursing
interventions cough effort. interventions

Vision: A globally competitive university for science, technology, and environmental conservation.
Mission: Development of a highly competitive human resource, cutting-edge scientific knowledge and innovative technologies for sustainable communities and environment.
 COLLEGE OF NURSING
Visca, Baybay City, Leyte, PHILIPPINES
Tel. no.: (053) 563-7226
Email address: nursing@vsu.edu.ph
Website: www.vsu.edu.ph

5. Encourage and 5. Helps in

- Patient will assess the patient to do breathing, clearing
References: demonstrate deep breathing the lungs and
relaxed manner, exercises providing comfort
 Doenges, M. E., resting/sleeping
Moorhouse, M. F., & Murr, after 6 hours of
A. C. (2019). Nursing nursing Dependent:
Care Plans 10th Edition. interventions a. Administer a. These
F.A. Davis Company. analgesics as medications are
prescribed and used to suppress
encourage the patient body discomfort
to take analgesics such as pain thus
before the pain enhancing rest and
worsens. comfort.

b. Administer b. These
antitussives as medications may be
indicated. used to reduce
excess mucus,
thereby enhancing
general comfort.

Collaborative:

i. Refer to a radio i. Evaluate and

technologist and assist examine organs or
for chest x-ray structures within the
procedures, as thorax
indicated.

Vision: A globally competitive university for science, technology, and environmental conservation.
Mission: Development of a highly competitive human resource, cutting-edge scientific knowledge and innovative technologies for sustainable communities and environment.