NURSING CARE PLAN

Nursing Problem Nursing Analysis Goal and Interventions Rationale Evaluatio

Cues Diagnosi Objectives n
s

Subjective Ineffecti Ineffectiv Goal: Was the

ve e Airway client
• Patient's airway Clearance After Nursing able to
chief clearanc Intervention have a
complain e r/t Inability the client will patent
was obstruct to clear be able to airway?
difficulty of ed secretions have a patent
breathing airway or airway __yes
• Has on and as obstructio clearance __no
off evidence ns from Why?
productive d by the
cough prior retained respirator
to secretio y tract to
admission ns maintain Objectives:
• With airway After series of
mechanical patency nursing
ventilator intervention
• Secretions the client will
are seen be able to
during INDEPENDENT
physical
assessmen 1.Ausculate the 1. Auscultating
t 1. the client’s lungs and Taking of
 client Vital signs will
will be be the base of
able to intervention
verbaliz
ea
clear
breathi
ng
pattern 2. Take V/S

2. Have a 3.For Proper

normal 3. Assist Client to lung
respirat Semi or High expansion
ory rate Fowlers
Position
3. have a
normal 4.Instruct Client to 4.For the
repirato do Breathing quick
ry Exercise expansion of
sound the lungs

5. Monitor Client
every hour

COLLABORATIVE

1. Administration
of 02 therapy
as ordered
COLLABORATIV
E

1. Oxygen is
essential
for cellmetaboli
sm, and in turn,
tissue
oxygenation is
essential for all
normal
physiological
functions.