NURSING CARE PLAN

NURSING
CUES OBJECTIVE INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

Subjective: Ineffective After 8 hours of rendering  Assessed respiratory  Use of accessory

“Ga lisud na syag nursing interventions, The movements and use muscles to breath
ginhawa tungod sa airway indicates an
client will be able to of accessory muscle.
plema nga di niya ma clearance r/t maintain airway patency abnormal increase in
gawas. Grabi na man ineffective work of breathing.
gud iyang ubo.” As
and will be able to
verbalized by the SO cough and expectorate retained  Monitored vital signs  To obtained baseline
retained secretions and maintain especially RR. data.
Objective: secretions. normal breathing pattern
 Auscutated the lung  Bronchial lung
sounds, noting areas sounds are
 Difficulty in
of decreased commonly heard
breathing.
ventilation and over areas of lung
density or
 Crackles on presence of
consolidation.
both lung adventitious sounds. Crackles are heard
fields. when fluid is present.
 Monitored chest x-
 Productive reports.  These determine
couch progression of
-Whitish color
 Encouraged client to disease process.
 Restless increase fluid intake.
 Hydration helps
decrease the
Vital signs taken:  Advised the relatives
viscosity of
elevate the bed atleast secretions facilitating
30 degress. expectorations.

 Assisted nebulizer  Positioning facilitates

treatment.
Nebulization done as
per doctor’s order
every 12hrs.
 Chest tapping
chest expansion and
respiratory efficiency
by reducing pressure
of abdominal organs
on diagram.
 performed after each  Relaxes bronchial
nebulization. and uterine smooth
muscle by acting on
 Instructed the client to beta-adrenergic
receptors.
have oral care after
each nebulization  Chest physiotherapy
helps to aid
 Provided immobilization of
supplemental fluids secretions

 Fluids regulated to
replace losses and
aid immobilization
secretions.