Names…Danso………Abigail………. Index No.…RGN423214….
Medical Condition…Broncholitis……………… Date …………16/05/2025……..
Patient Problems
1. The patient complains of difficulty in breathing.
2. Patient complains of loss of appetite.
3. The patient complains of a fever.
4. Nurses observe the patients for dehydration.
5. Patients' complaints of general body weakness
Patient / Family Strength
1. The patient is willing to be given oxygen therapy.
2. Patients can tolerate oral fluids.
3. Patience is willing to learn and follow the health instructions.
4. The patient is willing to be hydrated by following health instructions.
5. Patient is willing to be assisted to perform daily physical exercise.
Nursing care plan for the identified problems
Date/time Nursing diagnosis Objective/outcome Nursing order Intervention Evaluation
criteria
15/05/2025 Ineffective breathing 1. Patient will 1. Monitor 1. Respiration rate 17/05/2025
At pattern related to maintain breathing respiratory rate. was monitored. at
11:00 am airway inflammation pattern within 24-48 2. Administer 2. Prescribed oxygen 11:00 am
and mucus hours as evidenced oxygen. was administered. The goal was fully
obstruction by1. 3. Maintain airway 3. Airway clearance met, as evidenced by
clearance. was monitored by the Nurse observing
2. The nurse 4. Provide an suctioning the nasal the patient having a
observes that the additional pillow for passage. normal respiratory
patient is having a support. rate.
normal respiratory 5. Place the patient
rate and ease of in a comfortable
breathing. position (e.g, semi-
flower position).
Date/time Nursing diagnosis Objective/outcome Nursing order Intervention Evaluation
criteria
15/05/2025 Ineffective feeding The patient will 1. Monitor hydration 1. Patient took in 18/05/205
At pattern related to tolerate oral feeds status. fluids adequately and at
11:30 am difficulty in and show adequate 2. Offer small, showed signs of 11:30am
breathing and weight gain within 3 frequent feed. improved hydrated. The goal was fully
fatigue. days, as evidenced 3. Serve the patient 2. A well-nutritious met as evidenced by
by her favourite meal. diet was served to the patient being able
1. The patient can eat 4. Serve the patient the patient. to eat half of her
half of their favourite with nutritious diet. 3. The patient was favourite meal.
meal. served half of her
favourite meal
Date/time Nursing diagnosis Objective/outcome Nursing order Intervention Evaluation
criteria
15/05/2025 Hyperthermia related Temperature will 1. Monitor 1. Temperature was 16/05/2025
At to viral infection. reduce to the normal temperature every 4 monitored 4 hour 1. At
12:00am range within 24 hours. 2. Prescribed 12:00am
hours, as evidenced 2. Administer antipyretic was The goal was fully
by antipyretic as administered. met as evidenced by
1. The patient prescribed. 3. The patient was a the patient
verbalized that she is 3. Tepid, spongy tepid sponge. verbalizing feeling
feeling hot. patient. 4. Light clothing was hot.
4. Provide light provided, and patient
clothing and increase fluids were
fluid intake. increased.
Date/time Nursing diagnosis Objective/outcome Nursing order Intervention Evaluation
criteria
15/05/2025 Risk for fluids The patient will 1. Offer oral re- 1. The patient was 17/05/2025
At volume deficit maintain adequate hydration fluids re-hydrated At
1:00 pm related to poor hydration within 48 2. Monitor for signs 2. Signs of 1:00 am
feeding hours, as evidenced of dehydration dehydration were The goal was fully
by 3. Encourage fluids monitored met as evidenced by
1. Nurse observing intake 3. The patient was the Nurse observing
moist mucous 4. Monitor the intake encourage to take in moist mucous
membranes and and output chart. adequate fluids membranes and
adequate urine 4.The intake and adequate urine
output. output chart was output.
monitored.
Date/time Nursing diagnosis Objective/outcome Nursing order Intervention Evaluation
criteria
15/05/2025 Risk for infection The patient will be 1. Encourage rest 1. The patient rested 18/05/2025
At related to bronchitis relieved of general 2. Provide for 2 hours without At
2:45 pm body weakness additional pillows any difficulties 4:45 pm
within 24 hours, as for support 2. Additional pillows The goal was fully
evidenced by 3. Assist the patient were provided for met and as evidenced
1. The nurse to do physical patients by the nurse
observes that the exercise by using an 3. The patient was observing patients
patient is sleeping assistive device. assist to practice sleeping comfortably
comfortably. physical exercise in bed.
daily.
