LORMA COLLEGES CON TEMPLATE

NURSING CARE PLAN

RELATED LEARNING EXPERIENCE

STUDENT NAME: GARCIA, Pauline Antonette G. ROTATION: 7th AREA: Pediatric Intensive Care Unit

DATES: 06/21/21
YR LEVEL AND SEC: II DOROTHY JOHNSON   CLINICAL INSTRUCTOR: Dianne Altuhaini

Problem: Ineffective Breathing Pattern Diagnosis: Acute Asthma

Prioritization: High Date: 06/21/21

ASSESSMENT NURSING DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective: Ineffective breathing After 2-3 hours of Independent GOAL MET:

pattern related to nursing interventions,
“Ma…ma!!” cried by the 1. Monitor vital signs. 1. To obtain baseline data. After 2-3 hours of nursing
bronchoconstriction as patient will maintain
patient while gasping 2. Establish rapport with patient. 2. To gain patient’s trust and interventions, patient
evidenced by chest optimal breathing
for air. cooperation. maintained optimal
retractions, rhonchi and pattern, as evidenced 3. Assess the respiratory rate, 3. Changes in the respiratory rate breathing pattern, as
wheezes. by relaxed breathing, depth, and rhythm. and rhythm may indicate an manifested by relaxed
normal respiratory rate early sign of impending breathing, normal
and absence of respiratory distress.
respiratory rate and
Objective: dyspnea. 4. Assess the client’s level of 4. Anxiety may result from the
absence of dyspnea.
anxiety. struggle of not being able to
-Difficulty of breathing breathe properly.
seen with chest 5. Assess breath sounds, 5. Fatigue and adventitious sounds
retractions adventitious sounds such as mean worsening of the
wheezes and stridor and condition and indicate
-Rhonchi and wheezes
fatigue. impending respiratory failure.
are present
-Vital signs

T: 38.6 C 6. To maintain levels of oxygen,

PR: 100bpm 6. Provide oxygen (i.e., by mask). thereby helping the child
breathe.
RR: 28 bpm 7. Monitor oxygen saturation.
7. Too much oxygen can lead to
BP: 85/65 8. Position the patient in semi oxygen toxicity which can
O2 Sat: 90% fowler’s position. damage the lungs.

9. Provide good ventilation and 8. The position helps in lung

keep the environment dust expansion which can aid in
free. breathing.
10. Provide safety by raising side
rails. 9. For the comfort of the patient
and to avoid triggering allergic
response.
Dependent/Interdependent

11. Administer medications (i.e.,

10. To prevent the patient from
leukotriene modifiers,
falling.
antihistamine, bronchodilators
etc.) as prescribed.

11. To help manage the asthma,

which can facilitate effective
breathing pattern.

LORMA COLLEGES CON TEMPLATE

NURSING CARE PLAN
 RELATED LEARNING EXPERIENCE

STUDENT NAME: GARCIA, Pauline Antonette G. ROTATION: 7th AREA: Pediatric Intensive Care Unit

DATES: 06/21/21
YR LEVEL AND SEC: II DOROTHY JOHNSON   CLINICAL INSTRUCTOR: Dianne Altuhaini

Problem: Ineffective Airway Clearance Diagnosis: Acute Asthma

Prioritization: High Date: 06/21/21

ASSESSMENT NURSING DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective: Ineffective airway After 2-3 hours of Independent GOAL MET:
clearance related to nursing interventions,
“Iyak po sya ng iyak. At 1. Monitor vital signs. 1. To obtain baseline data. After 2-3 hours of nursing
swollen nasal mucosa patient will maintain
parang hindi po sya 2. Establish rapport with patient. 2. To gain patient’s trust and interventions, patient was
and increased airway patency as
makahinga ng maayos cooperation. able to maintain patent
pulmonary secretions as evidenced by clear 3. Assess the respiratory rate,
kaya dinala na po namin 3. Changes in the respiratory rate airway as evidenced by
evidenced by breath sounds and depth, and rhythm. and rhythm may indicate an
dito” as stated by the clear breath sounds and
adventitious lung normal rate and depth early sign of impending
patient’s mother. normal rate and depth of
sounds and increased of respiration. respiratory distress. respiration.
Objective: respiratory rate/rhythm. 4. Auscultate lungs for 4. Wheezes indicates partial
adventitious breath sounds. obstruction. Rhonchi may
-Nasal mucosa is boggy
indicate retained secretions in
with clear discharge
the lungs.
-Wheezes and rhonchi 5. Assess the effectiveness of 5. Coughing is the natural way to
cough. clear airway. Effective coughing
-Vital signs is very important to maintain
T: 38.6 C patency of airway.
6. Oxygen therapy corrects
PR: 100bpm 6. Provide oxygenation (i.e., by hypoxemia can be caused by
mask) retained respiratory secretions.
RR: 28 bpm
BP: 85/65

O2 Sat: 90% 7. Dehydration can contribute in

viscous secretions and may
7. Monitor and record intake and
result to decrease airway
output.
clearance.
8. Oxygen saturation of less than
90% indicates problems with
8. Monitor oxygen saturation.
oxygenation and too much
oxygenation can lead to oxygen
toxicity.
9. Helps loosen and expectorate
excess secretions; clear mucus
9. Encourage deep breathing and
out of the lungs.
coughing exercises.
10. Fluids help minimize mucosal
drying and increases ciliary
10. Encourage increased fluid
action to remove secretions.
intake of up to 3000 ml/day.
11. To prevent the patient from
falling.
11. Provide safety by raising side
rails.
12. To help manage the asthma,
which can effectively clear
Dependent/Interdependent
airway.
12. Administer IV fluids and
medication as ordered.

LORMA COLLEGES CON TEMPLATE

NURSING CARE PLAN
RELATED LEARNING EXPERIENCE
STUDENT NAME: GARCIA, Pauline Antonette G. ROTATION: 7th AREA: Pediatric Intensive Care Unit

DATES: 06/21/21
YR LEVEL AND SEC: II DOROTHY JOHNSON   CLINICAL INSTRUCTOR: Dianne Altuhaini

Problem: Fluid Volume Deficit Diagnosis: Acute Asthma

Prioritization: High Date: 06/21/21

ASSESSMENT NURSING DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective: Fluid volume deficit After 2-3 hours of Independent GOAL MET:
related to inadequate nursing interventions,
“Kapag pinapainom ko 1. Monitor vital signs. 1. To obtain baseline data. After 2-3 hours of nursing
fluid intake as patient fluid volume will
po sya ayaw po nyang 2. Establish rapport with patient. 2. To gain patient’s trust and interventions, patient
evidenced by sunken be maintained as
uminom. Nag-aalala po cooperation. fluid volume was
eyes, dry skin and poor evidenced by good skin 3. A common manifestation of
talaga ako kasi payo po 3. Monitor BP and HR for maintained as evidenced
skin turgor. turgor, moist skin and fluid loss is postural
ng doktor na dapat orthostatic changes. by good skin turgor, moist
absence of other signs hypotension.
tama yung fluid intake skin and absence of other
of dehydration. 4. Concentrated urine denotes
dahil side effect daw po 4. Assess color and amount of signs of dehydration.
ng asthma at mga urine. fluid deficit.
gamot nito ang 5. Note presence of nausea, 5. These factors influence intake,
dehydration” as vomiting and fever. fluid needs, and route of
expressed by the replacement.
patient’s mother. 6. Identify the possible cause of 6. To establish a database of the
the fluid disturbance or client’s history accurately and
Objective: provide individualized care.
imbalance.
-Sunken eyes
7. Urge the patient to drink 7. To improve the patient’s fluid
-Dry skin prescribed amount of fluid. balance.
-Skin goes back slowly
after pinching 8. Monitor and record intake and
output. 8. Doing this is essential in
-Vital signs determining the improvement
of the client’s condition
T: 38.6 C 9. Emphasize importance of oral suffering from dehydration.
hygiene. 9. Attention to mouth care
PR: 100bpm
promotes interest in drinking
RR: 28 bpm 10. Provide safety by raising side and reduces discomfort of dry
rails. mucous membranes.
BP: 85/65

O2 Sat: 90% 10. To prevent the patient from

falling.
Dependent/Interdependent

11. Administer fluids and

electrolytes as prescribed.

11. May be necessary to effectively

treat severe dehydration.