NURSING CARE PLAN

NURSING
CUES OBJECTIVE INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective: Ineffective airway STO: 1. Assess respiratory rate 1. Tachypnea and dyspnea Goal partially met
Nahihirapan akong clearance related to and depth, work of accompany by pulmonary respiratory rate
huminga as verbalized excessive mucus After 8 hours of nursing breathing ( use of obstruction, dyspnea and decresd from 32 cpm
by the patient. secretions and intervention, the patient accessory muscles/ nasal increased work of breathing to 28 cpm .
maybe first or only sign of
ineffective cough. will be able to maintain flaring, pursed-lip
sub-acute pulmonary embolus
Objective: respiratory status within breathing)
restlessness noted established parameters. 2. These parameters assist in
DOB 2. Assess activity determining client response to
Unproductive cough LTO: tolerance; encourage rest resumed activities and ability
periods, and limit activities to participate in self-care
accessory
After 2 days of holistic to client tolerance
muscle in breathing 3. Non ventilated may be
nursing care the pt. will be
changes in respiratory able to demonstrate 3. Auscultate lungs for identified by absence of breath
rate improve ventilation and area of decrease or absent sounds; crackles occur in fluid
adequate oxygenation of breath sounds and the filled tissues/ airways or may
reflect cardiac decompensation
tissues by ABGs oximetry presence of adventitious
Vital Signs: and to be free from sounds.
Temp:36.8 C 4. Promote maximal chest
symptoms of respiratory expansion, making it easier to
RR: 28 cpm distress 4. Elevate the head of the breath and enhancing
PR: 134 bpm bed as client physiologic/ psychologic
BP: 110/100 mmHg requires/tolerates. comfort.

5. Assist with frequency 5. Turning and ambulation

changes of position and enhance aerations of different
get client out of bed/ lung segments, thereby
ambulated as tolerated improving oxygen diffusion

6. Maximizes available oxygen

6. Administer for gas exchange, reducing
supplemental oxygen by work of breathing.
appropriate method.