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: 46Name of Client: Adela B. CruzAddress: 22 Halcion St., Brgy. Panatag, Mandaluyong CityInclusive Dates of Confinement: April 3- 5, 2021Nursing DiagnosisFormulate a Nursing CarePlan with at least threeprioritized (3) diagnoses:• Apply PES (Problem,Etiology, Signs &Symptoms for each nursingdiagnosis)• Use NANDA for etiologyNursing Diagnosis #1Subjective:Objective:Measurement:Nursing Diagnosis #2Subjective:Objective:Measurement:Nursing Diagnosis #3Subjective:Objective:Measurement:AnalysisGender: FemaleExample:Constipation occurs whenthe movement of feces.through the large intestine isslow, thus allowing time forreabsorption of fluid fromthe large intestine. Causesand factors contribute toconstipation includeinsufficient fiber intake,insufficient fluid intake,immobility, irregulardefecation habit, change indaily routine, lack ofprivacy, chronic use oflaxative or enemas,emotional disturbances suchas depression or mentalconfusion and medicationssuch as opiates or iron salts(Fundamentals of Nursingby Kozier, 2016, p. 1215).Ward/Room No.Attending Physician: Dr. Jerico Karl GarcesHealth Care Agency: San Jose District HospitalGoal & ObjectivesFormulate 1 goal and 2objectives each nursingdiagnosis (Total of 3 goalsand 6 objectives)Apply Time Frame,Behavior, Criteria ofAcceptable Performanceand Condition for eachobjectivesGoal:Objective #1:Objective #2:Goal:Objective #1:Objective #2:Goal:Objective #1:Objective #2:Nursing InterventionsFormulate 5 nursinginterventions per goal setcomplete with rationale(Total of 15 nursinginterventions and rationale)• Indicate the Independent,Dependent, andCollaborative nursingfunctions in the NursingInterventions column.Medical Diagnosis: AsthmaChief complaint: Difficulty of Breathingyou may use the book ofKozier for additional inputs1. Independent:2. Dependent:3. Collaborative:Rationale.. All nursing interventionhas corresponding rationale.EvaluationExample:The goal set for the clientwas:MetPartially MetUnmetAs evidenced by:1. The client statedunderstanding to at least 4strategies to manageconstipation within 3minutes time frame. Nursing Care Plan FormulationHISTORY OF PRESENT ILLNESS: On April 3, 2021 Aling Adela experienced difficulty of breathing. She was accompanied by her neighbor atZapanta Maternity Hospital and was given nebulization and unrecalled medications, 3 days PTA. Then she was brought again to San Jose DistrictHospital due to difficulty of breathing and coughRESULT 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 HgRR-32 bpmPR-88 bpmT- 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 Nursingpage 702 implies that the degree to which the skin protects the underlying tissues from injury depends on the general health of the cells, theamount of the subcutaneous tissue, and the dryness of the skin. Skin that is poorly nourished and dry is less easily protected and none vulnerableto 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. Facialexpression 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 shouldergirdle 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 FINDINGSA. Interaction PatternsAccording to the daughter of Aling Adela named Pat-pat, her mother is always busy at work. They (children) are always in-charged for planningactivities 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 becareful and take extra responsible.B. Economic PatternsAling 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 4:00AMand 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 needsas well as other expenses such as payment for food and education.C. Cognitive PatternsAling Adela just finished Grade 5 and has difficulty understanding her present condition. She sometimes cries at the corner and always thinks whatwould happen to her family if she suddenly passed away.List of Possible Nursing Diagnoses (Use NANDA for etiology)Ineffective Airway ClearanceManagement, ineffective therapeutic regimenImpaired Oral mucus membraneSelf care deficitImpaired skin IntegrityImpaired Role PerformanceHopelessnessAnticipatory GrievingPowerlessnessKnowledge DeficitImpaired Social InteractionImpaired Gas ExchangeIneffective CopingActivity IntoleranceAnxietyIneffective Breathing PatternRisk of InfectionList 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 atmospherepromote 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 thatdo 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 softensand 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 inmaintaining health status to improve ventilation).

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

Answered: direction: Formulate a Nursing Care…

6th Edition

ISBN:9781451194524

Author:Ruth McCall, Cathee M. Tankersley MT(ASCP)

Publisher:Ruth McCall, Cathee M. Tankersley MT(ASCP)

Chapter1: Phlebotomy: Past And Present And The Healthcare Setting

Section: Chapter Questions

Problem 1SRQ