direction: Formulate a Nursing Care Plan with at least three prioritized (3) diagnoses: Apply PES (Problem, Etiology, Signs & Symptoms fo each nursing diagnosis) 1 goal and 2 objectives each diagnosis, and 5 nursing interventions per goal set complete with rationale.

Reference: Nanda 2021-2023 | Kozier Fundamental of Nursing
Transcribed Image Text:Age: 46 Name of Client: Adela B. Cruz Address: 22 Halcion St., Brgy. Panatag, Mandaluyong City Inclusive Dates of Confinement: April 3- 5, 2021 Nursing Diagnosis Formulate a Nursing Care Plan with at least three prioritized (3) diagnoses: • Apply PES (Problem, Etiology, Signs & Symptoms for each nursing diagnosis) • Use NANDA for etiology Nursing Diagnosis #1 Subjective: Objective: Measurement: Nursing Diagnosis #2 Subjective: Objective: Measurement: Nursing Diagnosis #3 Subjective: Objective: Measurement: Analysis Gender: Female Example: Constipation occurs when the movement of feces. through the large intestine is slow, thus allowing time for reabsorption of fluid from the large intestine. Causes and factors contribute to constipation include insufficient fiber intake, insufficient fluid intake, immobility, irregular defecation habit, change in daily routine, lack of privacy, chronic use of laxative or enemas, emotional disturbances such as depression or mental confusion and medications such as opiates or iron salts (Fundamentals of Nursing by Kozier, 2016, p. 1215). Ward/Room No. Attending Physician: Dr. Jerico Karl Garces Health Care Agency: San Jose District Hospital Goal & Objectives Formulate 1 goal and 2 objectives each nursing diagnosis (Total of 3 goals and 6 objectives) Apply Time Frame, Behavior, Criteria of Acceptable Performance and Condition for each objectives Goal: Objective #1: Objective #2: Goal: Objective #1: Objective #2: Goal: Objective #1: Objective #2: Nursing Interventions Formulate 5 nursing interventions per goal set complete with rationale (Total of 15 nursing interventions and rationale) • Indicate the Independent, Dependent, and Collaborative nursing functions in the Nursing Interventions column. Medical Diagnosis: Asthma Chief complaint: Difficulty of Breathing you may use the book of Kozier for additional inputs 1. Independent: 2. Dependent: 3. Collaborative: Rationale .. All nursing intervention has corresponding rationale. Evaluation Example: The goal set for the client was: Met Partially Met Unmet As evidenced by: 1. The client stated understanding to at least 4 strategies to manage constipation within 3 minutes time frame.
Transcribed Image Text:Nursing Care Plan Formulation HISTORY OF PRESENT ILLNESS: On April 3, 2021 Aling Adela experienced difficulty of breathing. She was accompanied by her neighbor at Zapanta Maternity Hospital and was given nebulization and unrecalled medications, 3 days PTA. Then she was brought again to San Jose District Hospital due to difficulty of breathing and cough RESULT OF PHYSICAL ASSESSMENT (as of April 5, 2021): Client is wearing a "daster", she hasn't taken a bath for 2 days. Client stands 5'1" and weighs 50 kilograms. Her hair is not combed. Client cannot perform her activities of daily living. Vital signs take as follows: BP120/80 mm Hg RR-32 bpm PR-88 bpm T- 37.2 °C • Mrs. Cruz's skin is brown in color, no lesion but texture is rough and dry. The nurse recalls that according to Kozier, Fundamentals of Nursing page 702 implies that the degree to which the skin protects the underlying tissues from injury depends on the general health of the cells, the amount of the subcutaneous tissue, and the dryness of the skin. Skin that is poorly nourished and dry is less easily protected and none vulnerable to injury. Adela was also complaining "my skin is itchy, when I scratch it, it whitens out". • Examination of the skull shows no palpable mass, no lesions, hair are very distributed and black in color with some white strands. Facial expression due to difficult and labored breathing, there is flaring of nares and dryness of the mucus membrane. • Chest examination revealed crackles upon auscultation and she uses her accessory muscles of respiration to breathe, forcing the shoulder girdle upward causing supraclavicular fossae to on inspiration. Abdominal uscles also in her breathing. • Upper and lower extremities are symmetrical, no lesion, able to do simple extension, flexion, and no audible clicks heard during joint movement. Active range of motion exercises are not performed because it aggravates the difficulty of breathing. RESULT OF INTERVIEW WITH SIGNIFICANT FINDINGS A. Interaction Patterns According to the daughter of Aling Adela named Pat-pat, her mother is always busy at work. They (children) are always in-charged for planning activities at home. Sometimes if they are planning to go out as family, Aling Adela is not interested to join, she instead advises her children to be careful and take extra responsible. B. Economic Patterns Aling Adela is the only one who supports and works for her family. Her husband died a couple of years ago from emphysema. Aling Adela works as "laundry woman" in their neighborhood. And sometimes work as extra in the farm during harvest of rice. The client wakes up as early as 4:00AM and work until 6:00PM. Her eldest daughter Tin-tin admitted that the income of her mother is not sufficient to support them in their everyday needs as well as other expenses such as payment for food and education. C. Cognitive Patterns Aling Adela just finished Grade 5 and has difficulty understanding her present condition. She sometimes cries at the corner and always thinks what would happen to her family if she suddenly passed away. List of Possible Nursing Diagnoses (Use NANDA for etiology) Ineffective Airway Clearance Management, ineffective therapeutic regimen Impaired Oral mucus membrane Self care deficit Impaired skin Integrity Impaired Role Performance Hopelessness Anticipatory Grieving Powerlessness Knowledge Deficit Impaired Social Interaction Impaired Gas Exchange Ineffective Coping Activity Intolerance Anxiety Ineffective Breathing Pattern Risk of Infection List of Possible Nursing Interventions: (choose only 5 for each goals or you may use the book of Kozier for additional inputs) 1.) Encourage fluid intake especially water and fruit juices (fluid intake insures hydration and maintains moisture of the skin). 2.) Create a quiet, non disruptive environment with dim light and comfortable temperature when possible (comfort and quiet atmosphere promote a relaxed feeling and permit the client to focus on the relaxation technique rather than external extraction) 3.) Cleansing ad mild soap to clean the skin rather than soap and detergent (using mild cleansing agents avoid irritation and dryness and that do not disrupt the skin's natural barriers). 9.) Schedule necessary activities to provide periods of rest (to prevent fatigue and reduces 02 demands. 10.) Teach patient how to splint chest while coughing. (splinting reduces pain during coughing) 11.) Change patient position frequently (to maximize comfort) 4.) Apply emollients or moisturizing creams that contain lanolin, petroleum jelly or cocoa butter (it provides an oily film on the skin that softens and prevents evaporation and therefore chapping). 5.) Encourage sputum expectoration (to remove pathogens and prevent spread of infection). 6.) Teach patient Deep breathing exercise and coughing technique (to clear airways without fatigue). 7.) Perform postural drainage, percussion, and vibration (to facilitate secretion movement). 8.) Teach patient about pursed-lip breathing, abdominal breathing and performing relaxation techniques (to allow patient to participate in maintaining health status to improve ventilation).

Question

direction: Formulate a Nursing Care Plan with at least three prioritized (3) diagnoses: Apply PES (Problem, Etiology, Signs & Symptoms fo each nursing diagnosis) 1 goal and 2 objectives each diagnosis, and 5 nursing interventions per goal set complete with rationale.

Reference: Nanda 2021-2023 | Kozier Fundamental of Nursing

Age: 46
Name of Client: Adela B. Cruz
Address: 22 Halcion St., Brgy. Panatag, Mandaluyong City
Inclusive Dates of Confinement: April 3- 5, 2021
Nursing Diagnosis
Formulate a Nursing Care
Plan with at least three
prioritized (3) diagnoses:
• Apply PES (Problem,
Etiology, Signs &
Symptoms for each nursing
diagnosis)
• Use NANDA for etiology
Nursing Diagnosis #1
Subjective:
Objective:
Measurement:
Nursing Diagnosis #2
Subjective:
Objective:
Measurement:
Nursing Diagnosis #3
Subjective:
Objective:
Measurement:
Analysis
Gender: Female
Example:
Constipation occurs when
the movement of feces.
through the large intestine is
slow, thus allowing time for
reabsorption of fluid from
the large intestine. Causes
and factors contribute to
constipation include
insufficient fiber intake,
insufficient fluid intake,
immobility, irregular
defecation habit, change in
daily routine, lack of
privacy, chronic use of
laxative or enemas,
emotional disturbances such
as depression or mental
confusion and medications
such as opiates or iron salts
(Fundamentals of Nursing
by Kozier, 2016, p. 1215).
Ward/Room No.
Attending Physician: Dr. Jerico Karl Garces
Health Care Agency: San Jose District Hospital
Goal & Objectives
Formulate 1 goal and 2
objectives each nursing
diagnosis (Total of 3 goals
and 6 objectives)
Apply Time Frame,
Behavior, Criteria of
Acceptable Performance
and Condition for each
objectives
Goal:
Objective #1:
Objective #2:
Goal:
Objective #1:
Objective #2:
Goal:
Objective #1:
Objective #2:
Nursing Interventions
Formulate 5 nursing
interventions per goal set
complete with rationale
(Total of 15 nursing
interventions and rationale)
• Indicate the Independent,
Dependent, and
Collaborative nursing
functions in the Nursing
Interventions column.
Medical Diagnosis: Asthma
Chief complaint: Difficulty of Breathing
you may use the book of
Kozier for additional inputs
1. Independent:
2. Dependent:
3. Collaborative:
Rationale
.. All nursing intervention
has corresponding rationale.
Evaluation
Example:
The goal set for the client
was:
Met
Partially Met
Unmet
As evidenced by:
1. The client stated
understanding to at least 4
strategies to manage
constipation within 3
minutes time frame.

Nursing Care Plan Formulation
HISTORY OF PRESENT ILLNESS: On April 3, 2021 Aling Adela experienced difficulty of breathing. She was accompanied by her neighbor at
Zapanta Maternity Hospital and was given nebulization and unrecalled medications, 3 days PTA. Then she was brought again to San Jose District
Hospital due to difficulty of breathing and cough
RESULT OF PHYSICAL ASSESSMENT (as of April 5, 2021): Client is wearing a "daster", she hasn't taken a bath for 2 days. Client stands 5'1"
and weighs 50 kilograms. Her hair is not combed. Client cannot perform her activities of daily living.
Vital signs take as follows:
BP120/80 mm Hg
RR-32 bpm
PR-88 bpm
T- 37.2 °C
• Mrs. Cruz's skin is brown in color, no lesion but texture is rough and dry. The nurse recalls that according to Kozier, Fundamentals of Nursing
page 702 implies that the degree to which the skin protects the underlying tissues from injury depends on the general health of the cells, the
amount of the subcutaneous tissue, and the dryness of the skin. Skin that is poorly nourished and dry is less easily protected and none vulnerable
to injury. Adela was also complaining "my skin is itchy, when I scratch it, it whitens out".
• Examination of the skull shows no palpable mass, no lesions, hair are very distributed and black in color with some white strands. Facial
expression due to difficult and labored breathing, there is flaring of nares and dryness of the mucus membrane.
• Chest examination revealed crackles upon auscultation and she uses her accessory muscles of respiration to breathe, forcing the shoulder
girdle upward causing supraclavicular fossae to on inspiration. Abdominal uscles also in her breathing.
• Upper and lower extremities are symmetrical, no lesion, able to do simple extension, flexion, and no audible clicks heard during joint movement.
Active range of motion exercises are not performed because it aggravates the difficulty of breathing.
RESULT OF INTERVIEW WITH SIGNIFICANT FINDINGS
A. Interaction Patterns
According to the daughter of Aling Adela named Pat-pat, her mother is always busy at work. They (children) are always in-charged for planning
activities at home. Sometimes if they are planning to go out as family, Aling Adela is not interested to join, she instead advises her children to be
careful and take extra responsible.
B. Economic Patterns
Aling Adela is the only one who supports and works for her family. Her husband died a couple of years ago from emphysema. Aling Adela works as
"laundry woman" in their neighborhood. And sometimes work as extra in the farm during harvest of rice. The client wakes up as early as 4:00AM
and work until 6:00PM. Her eldest daughter Tin-tin admitted that the income of her mother is not sufficient to support them in their everyday needs
as well as other expenses such as payment for food and education.
C. Cognitive Patterns
Aling Adela just finished Grade 5 and has difficulty understanding her present condition. She sometimes cries at the corner and always thinks what
would happen to her family if she suddenly passed away.
List of Possible Nursing Diagnoses (Use NANDA for etiology)
Ineffective Airway Clearance
Management, ineffective therapeutic regimen
Impaired Oral mucus membrane
Self care deficit
Impaired skin Integrity
Impaired Role Performance
Hopelessness
Anticipatory Grieving
Powerlessness
Knowledge Deficit
Impaired Social Interaction
Impaired Gas Exchange
Ineffective Coping
Activity Intolerance
Anxiety
Ineffective Breathing Pattern
Risk of Infection
List of Possible Nursing Interventions:
(choose only 5 for each goals or you may use the book of Kozier for additional inputs)
1.) Encourage fluid intake especially water and fruit juices (fluid intake insures hydration and maintains moisture of the skin).
2.) Create a quiet, non disruptive environment with dim light and comfortable temperature when possible (comfort and quiet atmosphere
promote a relaxed feeling and permit the client to focus on the relaxation technique rather than external extraction)
3.) Cleansing ad mild soap to clean the skin rather than soap and detergent (using mild cleansing agents avoid irritation and dryness and that
do not disrupt the skin's natural barriers).
9.) Schedule necessary activities to provide periods of rest (to prevent fatigue and reduces 02 demands.
10.) Teach patient how to splint chest while coughing. (splinting reduces pain during coughing)
11.) Change patient position frequently (to maximize comfort)
4.) Apply emollients or moisturizing creams that contain lanolin, petroleum jelly or cocoa butter (it provides an oily film on the skin that softens
and prevents evaporation and therefore chapping).
5.) Encourage sputum expectoration (to remove pathogens and prevent spread of infection).
6.) Teach patient Deep breathing exercise and coughing technique (to clear airways without fatigue).
7.) Perform postural drainage, percussion, and vibration (to facilitate secretion movement).
8.) Teach patient about pursed-lip breathing, abdominal breathing and performing relaxation techniques (to allow patient to participate in
maintaining health status to improve ventilation).

Accepted Answer

Nursing care plan directs teh plan of care for a nurse. It is essential to formulate a nursing care…