NURSING CARE PLAN
NURSING
ASSESSMENT NURSING DIAGNOSIS PLANNING
Ineffective Breathing SHORT TERM:
Subjective:
Pattern related to an After 8 hours of nursing
infectious process of the intervention, patient will be
“ Inuubo at nahihirapan
lungs able to:
siyang huminga
minsan.” as verbalized  Verbalize understanding
by the SO and demonstrate proper
deep breathing
technique to facilitate
proper oxygenation to
alleviate
hyperventilation
Objective:
 difficulty of breathing
 chest xray
 O2: 94 %
LONG TERM:
After 2-3 days of nursing
intervention, patient will be
free of cyanosis and
establish normal breathing
pattern.
RATIONALE EVALUATION
INTERVENTIONS
1. Instructed patient to Increased mucus and
SHORT TERM:
increase oral fluid sputum secretions can
After 8 hours of nursing
intake to 8-10 glasses. lead to dehydration;
intervention, patient was able
increased water intake
to:
can help dissolve
secretions  Verbalize understanding
and demonstrate proper
deep breathing technique
2. Inspected for accessory These clinical signs are
to facilitate proper
muscle retraction, associated with oxygenation to alleviate
cyanosis, grunting on hypoxemia, atelectasis hyperventilation
expiration, and and pulmonary
restricted chest congestion. A baseline
movement. Auscultate assessment is performed
for bronchia breath to ascertain the degree of
sounds, inspiratory pulmonary congestion
crackles, increased and hypoxemia. LONG TERM:
vocal fremitus due to After 2-3 days of nursing
pleural effusion. intervention, patient was free
of cyanosis and establish
3. Instructed patient to do Deep breathing exercise normal breathing pattern.
deep breathing exercise increases oxygen intake
after demonstrating and can help alleviate
proper technique. dyspnea
4. Positioned the patient in It supports the
semi fowler’s position. diaphragm and allows
for deeper breaths.
 Presence may trigger
allergic response that
5. Kept environment may cause further
allergen free (dust, increase in mucus
feather pillows, smoke, secretion
pollen).

Collaborative:
1. Fixcom 1 tab BID
AC breakfast, PC
dinner