Nursing care plan for cellular abberations

1. NAME: Jonathan R. Yadao BSN-IIIC
SUBJECT: NCM 112:CELLULAR ABBERATIONS
NURSING CARE PLAN
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Objective:
+ 4 days’ difficulty of
breathing (dyspnea)
+ cough
+ fever
+ wheezing sounds
(upon auscultation)
VS taken as follows:
BP:130/80
RR: 28 bpm
PR: 125 bpm
O2Sat: 92%
Temp: 38oC
Ineffective breathing
pattern r/t
pneumonia
manifested by cough,
fever, dyspnea and
wheezing
After 2 days of nursing
intervention the patient
will be able:
 To demonstrate
appropriate
coping
behaviors to
relieve from
symptoms of
pneumonia and
to establish
normal/effective
breathing
pattern at
normal range.
 Establish rapport
 Monitor vital signs
and respirations.
 Auscultate chest
q2hrs.
 Reposition the
client.
 Administer
medication as
prescribed.
(antibiotics)
 Increase fluid
intake.
 To have nursing
patient interaction.
 To observe any
abnormalities of the
symptoms through
BP, RR, PR, o2sat
level and capillary
test if necessary.
 To identify breath
sounds and breathing
pattern
(regular/irregular)
 Assist the client/bed
to semi-fowler’s
/sitting position to
promotes chest
expansion to gain
more oxygen and to
release pressure on
the diaphragm for
proper circulation.
 To improve airway
patency and recover
from infection.
 To prevent from
dehydration.
After 2 days of nursing
intervention the patient
was able:
 To demonstrate
appropriate
coping
behaviors to
relieve from
symptoms of
pneumonia and
to establish
normal/effective
breathing
pattern at
normal range.
 The goal
partially `met.

2.  Promote deep
breathing and
coughing exercise.
 Promote for home
care medication.
 By clearing their
airways, patients can
keep their oxygen
levels stable. Teach
patients how to
cough profoundly
while keeping their
lips slightly open by
having them take a
big breath.
 Educate/demonstrate
home care
medication such as
nebulization, take
medication on time
and reduce heavy
workloads.