SAMPLE NURSING CARE PLAN

ASSESSMENT Subjective: Inuubo pa rin ako paminsan-minsan, pero hindi na tulad nung mga nakaraang araw. as verbalized by the patient Objective: Productive cough Body malaise Poor appetite With yellowish sticky mucous secretions Crackles breath sounds

DIAGNOSIS Ineffective airway clearance related to the presence of secretions

PLANING At the end of our duty shift, the patient must: Be able to cough out phlegm effectively Maintain airway patency

INTERVENTION Independent: Auscultate for breath sound

RATIONALE

EVALUATION At the end of our duty shift, the patient was able to: Maintain patent airway Expectorate sputum and cough effectively

To identify abnormal breath sounds To know the status or progress in/of the patient Helps to maintain hydration and fluid status, as well as to thin viscous secretions to allow To liquefy secretions

Monitor the vital signs

Regulate IVF as desired

Encourage patient to drink more water (should be warm)

Teach patient to do deep breathing exercises

To mobilize secretions so that patient may be able to more easily expectorate mucous secretions

Position patient to high fowlers position

To facilitate airway

Dependent: Administer medicines as prescribed by the physician To helps relief cough