Republic of the Philippines

SULTAN KUDARAT STATE UNIVERSITY

EJC Montilla, City of Tacurong, 9800 Province of Sultan Kudarat

Name of Patient: L. K. G. P Age/Sex: 8/ Male

Initial/ Admitting Diagnosis: SEPTIC SHOCK SECONDARY TO GLOMERULONEPHRITIS

NURSING CARE PLAN

ASSESSMENT NURSING PLANNING NURSING INTERVENTIONS RATIONALE EVALUATION
DIAGNOS
IS
05/06/2024 Risk for In 10 hours of A. Regular monitoring can GOAL PARTIALLY
A. Monitor vital signs every
08:00 pm Infection intervention the client detect early signs of MET
related to will be able to: hour. infection.
Subjective: impaired B. Assess wound for signs of B. Assessing a wound for After 10 hours of
“Natunok lang skin  remain free of infection (redness, swelling, signs of infection is vital intervention the client
na siya ma’am integrity of infection, as for prompt treatment. was able to:
warmth, pain, or discharge).
sang makahiya the left evidenced by C. Nutrition and hydration  demonstrated
bat apos gin try foot. normal vital C. Promote proper nutrition are crucial for maintaining a meticulous
ng kuhaon sang signs and the and fluids to support healing skin integrity and hand-washing
sibit, amo na absence of and immune function. supporting the immune technique and
dayun siya’’ as signs and system. proper wound
verbalized by symptoms of D. Ensure foot protection at D. Foot protection is care
the patient’s infection. all times to prevent further necessary to prevent management.
mother.  demonstrate a injury further injury and reduce
meticulous the risk of infection. However, patients
Objective: E. Reposition the patient E. Regular repositioning vital sign is not
hand-washing
 Edema & technique and regularly to alleviate pressure helps to prevent pressure stabilized. BP –
swelling proper wound and prevent the development injuries, which can be a 105/52, HR- 101, RR-
 Skin care of pressure injuries. source of infection 62, SpO2- 97%,
discoloration management F. Proper wound care and Temp- 37.3
 Painful F. Teach patient and family foot hygiene can prevent Also, patient is
 Inflamed left proper wound care and foot the spread of infections. Tachypneic.
foot. hygiene.
 Republic of the Philippines
SULTAN KUDARAT STATE UNIVERSITY
EJC Montilla, City of Tacurong, 9800 Province of Sultan Kudarat

Name of Patient: L. K. G. P Age/Sex: 8/ Male

Initial/ Admitting Diagnosis: SEPTIC SHOCK SECONDARY TO GLOMERULONEPHRITIS

NURSING CARE PLAN

ASSESSMENT NURSING PLANNING NURSING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
05/06/2024 Ineffective In 10 hours of 1. Regular monitoring allows GOAL
1. Monitor respiratory rate,
08:00 pm breathing intervention the for early detection of changes PARTIALLY MET
pattern client will be able rhythm, and depth. Note use in the patient's respiratory
Subjective: related to to: of accessory muscles to status. Use of accessory After 10 hours of
“Amo na siya airway breathe. muscles indicates increased intervention the
ma’am obstruction  demonstrat 2. Position the patient in a work of breathing and client was able to:
nabudlayan kag as evidence e improved potential respiratory distress.  demonstrat
dasig gin by semi-Fowler's position to 2. This position allows for
breathing e improved
ginhawa niya tachypnea, pattern as maximize lung expansion. optimal lung expansion, breathing
ba, kung wala use of evidenced 3. Administer supplemental improving oxygenation and pattern as
na oxygen accessory by a oxygen as ordered. reducing the work of evidenced
ma’am mas muscles to respiratory breathing. by a
budlayan pa gid breathe. RR rate within 4. Encourage the patient to 3. Supplemental oxygen respiratory
na siya’’ as of 64-52 normal take deep breaths and cough increases the amount of rate within
verbalized by cpm. range for every 1-2 hours. oxygen available for gas normal
the patient’s age, exchange, helping to correct range for
mother.  absence of 5. Administer bronchodilators hypoxia. age,
dyspnea and other prescribed 4. Deep breathing promotes no use of
Objective:  no use of medications to reduce airway full lung expansion and gas accessory
 Irritability accessory obstruction. exchange, while coughing muscles to
 Chest Pain muscles to helps to clear the airways of breathe
 Tachypnea 6. Provide a calm and restful secretions. So far, we've
breathe
 Use of environment to reduce 5. Bronchodilators relax the managed to lower
 Republic of the Philippines
SULTAN KUDARAT STATE UNIVERSITY
EJC Montilla, City of Tacurong, 9800 Province of Sultan Kudarat

muscles around the airways, the patient's RR to

anxiety and minimize oxygen
reducing obstruction and 49, but the patient's
demand. improving airflow. breathing is still not
7. Educate the patient and 6. Anxiety can increase the stable.
accessory family about the importance rate and work of breathing,
muscles to thereby increasing oxygen
of adhering to the prescribed
breath demand. A calm environment
 Vital signs: treatment plan. helps to reduce anxiety and
Temp: 38.1 promote relaxation.
HR: 123 7. Understanding the
RR: 64 - 52 importance of the treatment
plan can improve adherence,
leading to better
management of the patient's
condition.