ZAMORA, Brylle S.

Leadership and Management / Ma’am Jennifer Padual

BSN118 / Group 72 B February 10, 2011 / Head nurse: Karen Maeve Villa

NURSING CARE PLAN

CUES ANALYSIS NURSING GOAL AND INTERVENTION RATIONALE EVALUATION

DIAGNOSIS OBJECTIVES
Subjective: Respiratory
N/A pattern Ineffective After 24 hours of After 24 hours of
monitoring airway nursing intervention nursing
Objective: addresses the clearance the client will be able intervention the
patient’s related to to have an improved client was able to
Vital signs ventilatory decreased breathing pattern. manifest signs of
RR – 24 cpm pattern, rate, energy or improved
and depth. fatigue as After 8 hours of breathing.
Temp – 36.6 Most acute manifested by nursing intervention
pulmonary of accessory the health care
BP – 110/60 deterioration is muscles during provider will be able
preceded by a respiratory to perform the Talk to the client and
PR – 72 bpm change in ventilation and following: interact with him to
breathing nasal have his trust. If the client is
*patient is pattern. congestion. 1. Gain client’s comfortable with you
irritable Respiratory attention and being around,
failure can be build affinity. interventions will be
* patient is seen with a Assess airway for easier to execute.
crying change in patency.
respiratory rate, Maintaining the
* increase in change in airway is always the
chest normal first priority, especially
expansion; abdominal and in cases of trauma,
noted. thoracic acute neurological
patterns for decompensation, or
inspiration and Auscultate lungs for cardiac arrest.
expiration, presence of normal
change in depth or adventitious
of ventilation breath sounds,
(Vt), and Decreased or absent
respiratory breath sounds These
alternans. may indicate
Breathing presence of mucus
pattern plug or other major
changes may airway obstruction.
occur in a
multitude of Wheezing These may
cases from indicate increasing
hypoxia, heart airway resistance.
failure,
diaphragmatic
paralysis, Coarse sounds These
airway Assess respirations; may indicate
obstruction, note quality, rate, presence of fluid
infection, pattern, depth, flaring along larger airways.
neuromuscular of nostrils, dyspnea
impairment, on exertion, evidence Abnormality indicates
trauma or of splinting, use of respiratory
surgery accessory muscles, compromise.
resulting in and position for
musculoskeletal breathing.
impairment
and/or pain, Assess changes in
cognitive mental status.
impairment and
anxiety, Increasing lethargy,
metabolic confusion,
abnormalities restlessness, and/or
(e.g., diabetic irritability can be early
ketoacidosis Assess changes in signs of cerebral
[DKA], uremia, vital signs and hypoxia.
or thyroid temperature.
dysfunction), Tachycardia and
peritonitis, drug hypertension may be
overdose, and related to increased
pleural
inflammation. work of breathing.
Fever may develop in
Assess cough for response to retained
effectiveness and secretions/atelectasis.
productivity.
Consider possible
causes for ineffective
cough (e.g.,
respiratory muscle
fatigue, severe
Note presence of bronchospasm, or
sputum; assess thick tenacious
quality, color, secretions).
amount, odor, and
consistency.
This may be a result
of infection,
bronchitis, chronic
smoking, or other
condition. A sign of
infection is discolored
sputum (no longer
clear or white); an
Assess for pain odor may be present.

Postoperative pain
can result in shallow
breathing and an
Assist patient in ineffective cough.
2. Perform performing coughing
therapeutic and breathing These improve
interventions maneuvers. productivity of the
to the patient cough.

Use positioning (if

tolerated, head of
 bed at 45 degrees;
sitting in chair,
ambulation). These promote better
lung expansion and
Administer improved air
medications (e.g., exchange.
antibiotics, mucolytic
agents,
bronchodilators,
expectorants) as
ordered, noting
effectiveness and
side effects.

3. Conduct
health
teaching with Instruct mother in the
the mother. following:

• Optimal
positioning
(sitting Directed coughing
position) techniques help
• Use of pillow mobilize secretions
or hand from smaller airways
splints when to larger airways
coughing because the coughing
• Use of is done at varying
abdominal times. The sitting
muscles for position and splinting
more forceful the abdomen promote
cough more effective
• Use of quad coughing by
and huff increasing abdominal
techniques pressure and upward
 • Use of
incentive diaphragmatic
spirometry movement.
• Importance
of
ambulation
and frequent
position
changes

• Encourage
oral intake of Increased fluid intake
fluids within reduces the viscosity
the limits of of mucus produced by
cardiac the goblet cells in the
reserve airways. It is easier
for the patient to
mobilize thinner
4. Provide secretions with
teaching coughing.
regarding
things to Tell to the mother the
remember ff:
once the
client is
discharge. Demonstrate and
teach coughing,
Patient will
deep breathing,
understand the
and splinting rationale and
techniques. appropriate
techniques to keep
the airway clear of
secretions.
Explain effects of
smoking, including Smoking contributes
second-hand smoke. to bronchospasm and
increased mucus
production in the
airways.
Instruct on
indications for,
frequency, and side
effects of
medications

Instruct how to use

prescribed inhalers,
as appropriate.

In home setting,
instruct regarding
cough enhancement
techniques and need
for humidification.

Teach about
environmental
factors that can
precipitate
respiratory problems.