Community Nursing Care Plan
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NURSING CARE PLAN Marife: 45 years old ASSESSMENT
Subjective: “Minsan nahihirapan akong himinga dahil sa sipon.” Objective: >Presence of yellowish sputum >Absent cough >Teary eyes
DIAGNOSIS
Ineffective airway clearance r/t retained secretions as evidenced by presence of secretions.
BACKGROUND STUDY/ DEFINITION Irritant (inhalation)
PLANNING
After 4 hours of nursing intervention the ct’s secretions are mobilize and airway is maintain free of Inflammatory response secretions, as evidenced by clear lung sounds and ability to effectively cough up Increased production of secretions secretions
Airway constriction
IMPLEMENTATION
>Elevate head of the bed or place high pillow on the head; have the ct. lean on overhead table or sit on the edge of the bed.
RATIONALE
>Elevation of the bed facilitates respiratory function by use of gravity.
>Keep environmental >Precipitators of pollution to a minimum allergic type of like dust, and smoke. respiratory reactions that can trigger or exacerbate onset of acute episode. >Instruct ct. in coughing and deep breathing.
> To improve cough effectiveness and facilitate removal of secretions.
>Increased fluid intake to 300 ml/day. Provide warm or tepid liquids.
>Hydration helps decrease the viscosity of secretions, facilitating expectoration. Using warm liquid may decrease bronchospasm.
EXPECTED OUTCOME/ EVALUATION Goal met: After 4 hours of nursing intervention the ct’s secretions are mobilized and airway is maintained free of secretions, as evidenced by clear lung sounds and ability to effectively cough up secretions
Dyspnea
Reference: Understanding Pathophysiology Huether
LUWALHATI B. CENSON BSN-2B Grp. 2
NURSING CARE PLAN Ana: 24 years old ASSESSMENT
DIAGNOSIS
BACKGROUND STUDY/ DEFINITION Subjective: Stress overload r/t Stress is an e inadequate resources vent or set of “Naiistress ako sa (financial) as circumstances causing pagbubuntis dahil hindi verbalized by the ct. a disrupted response; pa kami handa “Naiistress ako sa the disruption caused financially.” pagbubuntis dahil hindi by a noxious stimuli or pa kami handa stressor. Objective: financially.” >Stress rate of 9 >Demonstrate feeling of weakness, pressure and tension. >Seems tired and restless >Pale skin and lips >Poor eye contact >Facial tension
Reference:: Fundamentals of Nursing Barbara Kozier
PLANNING
After 2 days of nursing intervention the ct will be able: >to reduce stress rate from 9 to 2 >report anxiety at manageable level >describe and plan effective ways to reduce stress
IMPLEMENTATION
RATIONALE
>Assess ct.’s level of stress. Validate by saying to ct. “Are you feeling stress now?”
>Stress is highly individualized, normal, physical, and psychological response to internal and external life events.
>Allow and reinforce ct.’s personal reaction to discomfort and threats.
>Talking or otherwise expressing feelings sometimes reduces stress and anxiety.
>Encourage to identify her own strengths and abilities..
> Assist the ct. to develop appropriate strategies for coping based on personal strengths and previous experiences. Improves self concept and sense of ability to manage stress.
>Identify the degree of family support..
>Assessing family interaction serves as a basis for identifying support systems or lack thereof.
EXPECTED OUTCOME/ EVALUATION Goal met: After 2 days of nursing intervention the ct was able: >to reduce stress rate from 9 to 2 >reported anxiety at manageable level >described and planned effective ways to reduce stress
LUWALHATI B. CENSON BSN-2B Grp. 2
NURSING CARE PLAN Jinggoy: 8 years old ASSESSMENT
Subjective: >“Minsan lang ako magtoothbrush, pagnaisipan.” >Toothache Objective: >Enamel discoloration >Erosion of tooth enamel >Excessive plaque >Tooth fractures >Halitosis
DIAGNOSIS
Impaired dentition r/t ineffective oral hygiene as manifested by toothache and halitosis.
BACKGROUND STUDY/ DEFINITION
PLANNING
IMPLEMENTATION
Tooth decay, which is also called dental cavities or dental caries, is the destruction of the outer surface (enamel) of a tooth. Decay results from the action of bacteria that live in plaque, which is a sticky, whitish film formed by a protein in saliva (mucin) and sugary substances in the mouth. The plaque bacteria sticking to tooth enamel use the sugar and starch from food particles in the mouth to produce acid.
After 3 days of nursing intervention the ct will be able to: >lessen the toothache felt by the client >improve breath odor >perform correct way of brushing and flossing the teeth independently.
>Teach and demonstrate the correct way of brushing and flossing the teet >Advice to rinse with mouthwash or sol of warm water and salt or baking soda
>Refer to a dental hygienist, dentist, or clinic as needed
RATIONALE
EXPECTED OUTCOME/ EVALUATION >To gain knowledge Goal met: about proper way of removing debris on After 3 days of the teeth nursing intervention the ct was able to: >To loosen left food >lessened the particles, washes toothache felt by the out already client loosened particles >improved breath and improve breath odor odor >performed correct way of brushing and > To check the flossing the teeth severity of tooth independently. damage and have the medication as needed.
Reference: http://www.healthatoz.co m/healthatoz/ Atoz/common/standard/tr ans form.jsp?requestURI=/ healthatoz/Atoz/ency/toot h_decay.jsp
LUWALHATI B. CENSON BSN-2B Grp. 2
NURSING CARE PLAN Linda: 79 y/o ASSESSMENT
Subjective: Objective:
DIAGNOSIS
Risk for falls r/t foot problem
BACKGROUND STUDY/ DEFINITION Risk for fall is the increased susceptibility to falling that may cause physical harm
>age 65 and over >foot problem >gait difficulty
PLANNING
After 5 hours of nursing intervention the client will have decrease risk for fall as demonstrated by knowledge about fall prevention.
IMPLEMENTATION
RATIONALE
>Assess the client’ ability to ambulate safely with or without assistive devices.
>Assessment help th nurse recommend safety measures to the ct. and family.
>Provide information on environmental hazards and characteristics (stairs, windows, gates).
>Obtaining knowledge can reduce the risk of falling.
>Ensure that the ct. wears proper shoes (nonskid shoes, secure fastener).
>Wearing slippery and ill-fitted shoes increases the risk of falling
EXPECTED OUTCOME/ EVALUATION Goal met: After 5 hours of nursing intervention the client had decreased risk for fall as demonstrated by knowledge about fall prevention.
Reference:: Nursing Diagnosis Handbook Judith Wilkinson
LUWALHATI B. CENSON BSN-2B Grp. 2
NURSING CARE PLAN Totoy: 3y/o ASSESSMENT
Subjective: “Inuubo siya at sinisipon” As verbalized by the mother Objective: >Use of accessory muscle >Abnormal breath sounds. >Cough with phlegm
DIAGNOSIS
Ineffective airway clearance r/t increase production of secretions
BACKGROUND STUDY/ DEFINITION Increased amount and viscosity of secretions And/or inability to clear secretions through the normal cough mechanism may lead to pooling of secretions in lower airways. Pooling of secretions leads to inadequate gas exchenge.
Reference: Nettina, Manual of Nursing Practice
PLANNING
After 3 days of nursing intervention the ct will demonstrate behaviors to improve airway clearance.
IMPLEMENTATION
RATIONALE
> Assess cough for effectiveness and productivity.
> Consider possible causes for ineffective cough (e.g., respiratory muscle fatigue, severe bronchospasm, or thick tenacious secretions).
> Use positioning (if tolerated, head of bed at 45 degrees; sitting in chair, ambulation).
> These promote better lung expansion and improved air exchange.
> Encourage oral intake of fluids within the limits of cardiac reserve.
> Increased fluid intake reduces the viscosity of mucus produced by the goblet cells in the airways. It is easier for the patient to mobilize thinner secretions with coughing.
> Demonstrate and teach coughing, deep breathing, and splinting techniques.
> Patient will understand the rationale and appropriate techniques to keep the airway clear of secretions.
EXPECTED OUTCOME/ EVALUATION Goal met: After 3 days of nursing intervention the ct demonstrated behaviors to improved airway clearance.
LUWALHATI B. CENSON BSN-2B Grp. 2
Health Teaching DATE AND TIME
OBJECTIVES
The health teaching was held at Poblacion. Iba Hagonoy, Bulaca:n last March 2, 2009 at 8:00 in the morning
After health teaching the client(pregnant and children) and their significant others will be able to: >gain knowledge about stress management >formulate own coping mechanism for stress >know what family planning is and its importance >decide to plan for their family. >gain knowledge and know the importance of bathing, grooming and oral hygiene >learn the proper ways of performing self care through hygienic practices.
LEARNING CONTENT The health teaching contains: >Stress management -definition of stress -ways on how to deal with stress during pregnancy. >Family planning -definition of family planning -importance of family planning -types of contraceptives that could be used. >Hygiene -Bathing and Grooming -importance and proper way -effects or consequences of lack of bathing -Oral Hygiene -proper way of brushing and flossing the teeth -effects of ineffective oral care
STRATEGY
RESOURCES
TARGET
> Interactive discussion >Manpower
> Pregnant
>Question and answer
>Children ages 6 to 12
- Group 2, 2B >Books -Fundamentals of Nursing (7th Edition By Barbara Kozier) - Maternal and Child Health Nursing (Care of the Child Bearing and Child Rearing Family by Adelle Pillitteri)
EXPECTED OUTCOME After health teaching the pregnant, children and their significant others was able to:
>Significant others >gain knowledge about stress management >verbalized ways on how to cope up with stress >knew what family planning was and its importance >decided to plan for their family >gained knowledge and knew the importance of bathing, grooming and oral hygiene >learned and verbalized the proper ways of performing self care through hygienic practices. LUWALHATI B. CENSON BSN-2B Grp. 2
Subjective: “Minsan nahihirapan akong himinga dahil sa sipon.” Objective: >Presence of yellowish sputum >Absent cough >Teary eyes
DIAGNOSIS
Ineffective airway clearance r/t retained secretions as evidenced by presence of secretions.
BACKGROUND STUDY/ DEFINITION Irritant (inhalation)
PLANNING
After 4 hours of nursing intervention the ct’s secretions are mobilize and airway is maintain free of Inflammatory response secretions, as evidenced by clear lung sounds and ability to effectively cough up Increased production of secretions secretions
Airway constriction
IMPLEMENTATION
>Elevate head of the bed or place high pillow on the head; have the ct. lean on overhead table or sit on the edge of the bed.
RATIONALE
>Elevation of the bed facilitates respiratory function by use of gravity.
>Keep environmental >Precipitators of pollution to a minimum allergic type of like dust, and smoke. respiratory reactions that can trigger or exacerbate onset of acute episode. >Instruct ct. in coughing and deep breathing.
> To improve cough effectiveness and facilitate removal of secretions.
>Increased fluid intake to 300 ml/day. Provide warm or tepid liquids.
>Hydration helps decrease the viscosity of secretions, facilitating expectoration. Using warm liquid may decrease bronchospasm.
EXPECTED OUTCOME/ EVALUATION Goal met: After 4 hours of nursing intervention the ct’s secretions are mobilized and airway is maintained free of secretions, as evidenced by clear lung sounds and ability to effectively cough up secretions
Dyspnea
Reference: Understanding Pathophysiology Huether
LUWALHATI B. CENSON BSN-2B Grp. 2
NURSING CARE PLAN Ana: 24 years old ASSESSMENT
DIAGNOSIS
BACKGROUND STUDY/ DEFINITION Subjective: Stress overload r/t Stress is an e inadequate resources vent or set of “Naiistress ako sa (financial) as circumstances causing pagbubuntis dahil hindi verbalized by the ct. a disrupted response; pa kami handa “Naiistress ako sa the disruption caused financially.” pagbubuntis dahil hindi by a noxious stimuli or pa kami handa stressor. Objective: financially.” >Stress rate of 9 >Demonstrate feeling of weakness, pressure and tension. >Seems tired and restless >Pale skin and lips >Poor eye contact >Facial tension
Reference:: Fundamentals of Nursing Barbara Kozier
PLANNING
After 2 days of nursing intervention the ct will be able: >to reduce stress rate from 9 to 2 >report anxiety at manageable level >describe and plan effective ways to reduce stress
IMPLEMENTATION
RATIONALE
>Assess ct.’s level of stress. Validate by saying to ct. “Are you feeling stress now?”
>Stress is highly individualized, normal, physical, and psychological response to internal and external life events.
>Allow and reinforce ct.’s personal reaction to discomfort and threats.
>Talking or otherwise expressing feelings sometimes reduces stress and anxiety.
>Encourage to identify her own strengths and abilities..
> Assist the ct. to develop appropriate strategies for coping based on personal strengths and previous experiences. Improves self concept and sense of ability to manage stress.
>Identify the degree of family support..
>Assessing family interaction serves as a basis for identifying support systems or lack thereof.
EXPECTED OUTCOME/ EVALUATION Goal met: After 2 days of nursing intervention the ct was able: >to reduce stress rate from 9 to 2 >reported anxiety at manageable level >described and planned effective ways to reduce stress
LUWALHATI B. CENSON BSN-2B Grp. 2
NURSING CARE PLAN Jinggoy: 8 years old ASSESSMENT
Subjective: >“Minsan lang ako magtoothbrush, pagnaisipan.” >Toothache Objective: >Enamel discoloration >Erosion of tooth enamel >Excessive plaque >Tooth fractures >Halitosis
DIAGNOSIS
Impaired dentition r/t ineffective oral hygiene as manifested by toothache and halitosis.
BACKGROUND STUDY/ DEFINITION
PLANNING
IMPLEMENTATION
Tooth decay, which is also called dental cavities or dental caries, is the destruction of the outer surface (enamel) of a tooth. Decay results from the action of bacteria that live in plaque, which is a sticky, whitish film formed by a protein in saliva (mucin) and sugary substances in the mouth. The plaque bacteria sticking to tooth enamel use the sugar and starch from food particles in the mouth to produce acid.
After 3 days of nursing intervention the ct will be able to: >lessen the toothache felt by the client >improve breath odor >perform correct way of brushing and flossing the teeth independently.
>Teach and demonstrate the correct way of brushing and flossing the teet >Advice to rinse with mouthwash or sol of warm water and salt or baking soda
>Refer to a dental hygienist, dentist, or clinic as needed
RATIONALE
EXPECTED OUTCOME/ EVALUATION >To gain knowledge Goal met: about proper way of removing debris on After 3 days of the teeth nursing intervention the ct was able to: >To loosen left food >lessened the particles, washes toothache felt by the out already client loosened particles >improved breath and improve breath odor odor >performed correct way of brushing and > To check the flossing the teeth severity of tooth independently. damage and have the medication as needed.
Reference: http://www.healthatoz.co m/healthatoz/ Atoz/common/standard/tr ans form.jsp?requestURI=/ healthatoz/Atoz/ency/toot h_decay.jsp
LUWALHATI B. CENSON BSN-2B Grp. 2
NURSING CARE PLAN Linda: 79 y/o ASSESSMENT
Subjective: Objective:
DIAGNOSIS
Risk for falls r/t foot problem
BACKGROUND STUDY/ DEFINITION Risk for fall is the increased susceptibility to falling that may cause physical harm
>age 65 and over >foot problem >gait difficulty
PLANNING
After 5 hours of nursing intervention the client will have decrease risk for fall as demonstrated by knowledge about fall prevention.
IMPLEMENTATION
RATIONALE
>Assess the client’ ability to ambulate safely with or without assistive devices.
>Assessment help th nurse recommend safety measures to the ct. and family.
>Provide information on environmental hazards and characteristics (stairs, windows, gates).
>Obtaining knowledge can reduce the risk of falling.
>Ensure that the ct. wears proper shoes (nonskid shoes, secure fastener).
>Wearing slippery and ill-fitted shoes increases the risk of falling
EXPECTED OUTCOME/ EVALUATION Goal met: After 5 hours of nursing intervention the client had decreased risk for fall as demonstrated by knowledge about fall prevention.
Reference:: Nursing Diagnosis Handbook Judith Wilkinson
LUWALHATI B. CENSON BSN-2B Grp. 2
NURSING CARE PLAN Totoy: 3y/o ASSESSMENT
Subjective: “Inuubo siya at sinisipon” As verbalized by the mother Objective: >Use of accessory muscle >Abnormal breath sounds. >Cough with phlegm
DIAGNOSIS
Ineffective airway clearance r/t increase production of secretions
BACKGROUND STUDY/ DEFINITION Increased amount and viscosity of secretions And/or inability to clear secretions through the normal cough mechanism may lead to pooling of secretions in lower airways. Pooling of secretions leads to inadequate gas exchenge.
Reference: Nettina, Manual of Nursing Practice
PLANNING
After 3 days of nursing intervention the ct will demonstrate behaviors to improve airway clearance.
IMPLEMENTATION
RATIONALE
> Assess cough for effectiveness and productivity.
> Consider possible causes for ineffective cough (e.g., respiratory muscle fatigue, severe bronchospasm, or thick tenacious secretions).
> Use positioning (if tolerated, head of bed at 45 degrees; sitting in chair, ambulation).
> These promote better lung expansion and improved air exchange.
> Encourage oral intake of fluids within the limits of cardiac reserve.
> Increased fluid intake reduces the viscosity of mucus produced by the goblet cells in the airways. It is easier for the patient to mobilize thinner secretions with coughing.
> Demonstrate and teach coughing, deep breathing, and splinting techniques.
> Patient will understand the rationale and appropriate techniques to keep the airway clear of secretions.
EXPECTED OUTCOME/ EVALUATION Goal met: After 3 days of nursing intervention the ct demonstrated behaviors to improved airway clearance.
LUWALHATI B. CENSON BSN-2B Grp. 2
Health Teaching DATE AND TIME
OBJECTIVES
The health teaching was held at Poblacion. Iba Hagonoy, Bulaca:n last March 2, 2009 at 8:00 in the morning
After health teaching the client(pregnant and children) and their significant others will be able to: >gain knowledge about stress management >formulate own coping mechanism for stress >know what family planning is and its importance >decide to plan for their family. >gain knowledge and know the importance of bathing, grooming and oral hygiene >learn the proper ways of performing self care through hygienic practices.
LEARNING CONTENT The health teaching contains: >Stress management -definition of stress -ways on how to deal with stress during pregnancy. >Family planning -definition of family planning -importance of family planning -types of contraceptives that could be used. >Hygiene -Bathing and Grooming -importance and proper way -effects or consequences of lack of bathing -Oral Hygiene -proper way of brushing and flossing the teeth -effects of ineffective oral care
STRATEGY
RESOURCES
TARGET
> Interactive discussion >Manpower
> Pregnant
>Question and answer
>Children ages 6 to 12
- Group 2, 2B >Books -Fundamentals of Nursing (7th Edition By Barbara Kozier) - Maternal and Child Health Nursing (Care of the Child Bearing and Child Rearing Family by Adelle Pillitteri)
EXPECTED OUTCOME After health teaching the pregnant, children and their significant others was able to:
>Significant others >gain knowledge about stress management >verbalized ways on how to cope up with stress >knew what family planning was and its importance >decided to plan for their family >gained knowledge and knew the importance of bathing, grooming and oral hygiene >learned and verbalized the proper ways of performing self care through hygienic practices. LUWALHATI B. CENSON BSN-2B Grp. 2
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