NURSING CARE PLAN No.

Assessment Nursing Planning Intervention Rationale Evaluation

Diagnosis
Subjective: Ineffective airway Short term goal: Independent   Short term goal:
 “May halak pa sya clearance due to · After 8 hours of -Assess vital signs  -To provide baseline data.  GOAL
at may plema pa rin increased sputum nursing PARTIALLY
pag ubo nya” as production. intervention, the -Assess respiratory -use of accessory muscle indicates an MET
verbalized by the client’s airway movements and use of abnormal increase in work of  
client’s father. will be free of accessory muscles. breathing.
  secretions as
evidenced by -Assess sputum color, -A sign of infection is discoloured
Objective: clear lung amount, and odor and sputum. An odor may be present.
-patient sounds after report
demonstrates coughing. Long term goal:
persistent coughing -Teach mother chest -Chest physiotherapy includes the GOAL
  physiotherapy techniques of postural drainage and PARTIALLY
(+) crackles Long term goal: chest percussion to mobilize METMET
· After 4 days of secretions from smaller airways that
v/s nursing cannot be eliminated by means of
T= 36.2 °C intervention, the coughing or suctioning.
P= 120 bpm client will be
R= 33 cpm able to have -Encourage hydration -To loosen secretion
effective airway at least 8 glasses of
clearance and no water/day
sputum -Facilitates liquefaction and removal
productions with -Assist with nebulizer of secretions.
normal lung treatments.
sounds

Dependent
-Administer medication
such as bronco dilators To promote pharmacologic
regimen
Collaboration
-Refer to the pulmonary -Consultants may be helpful in
clinical nurse specialist, ensuring that proper
home health nurse, or
respiratory therapist as treatments are met.
indicated.