PHINMA University of Pangasinan

College of Health Sciences

NURSING CARE PLAN

ASSESSMENT NURSING ANALYSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective:
 “Nahihirapan ako  After 4 hours of nursing  Assist patient to assume  Elevation of the head of  After 4 hours of nursing
huminga” as interventions, the client will position of comfort, e.g., the bed facilitates interventions, the client
verbalized by the demonstrate behaviors to elevate head of bed, respiratory function by was able to
patient improve airway clearance e.g. encourage patient to lean use of gravity demonstrate behaviors
cough effectively and on overbed table or sit on to improve airway
expectorate secretions. the edge of the bed. clearance e.g., cough
Objective: effectively and
Vital signs:  Keep environmental  Precipitators of allergic expectorate secretions.
 BP 100/80 pollution to a minimum type or respiratory
 Temp 36.2 e.g., dust, smoke and reactions that can
 RR-20 feather pillows. According trigger or exacerbate
to individual situation. onset of acute episode.

 Encourage or assist with  Provides patient with

NURSING DIAGNOSIS pursed lip breathing some means to cope or
Ineffective airway exercises. control dyspnea and
clearance related to reduce air trapping.
increased production of
secretions.
 Administer medication as  A variety of
prescribed by the medications may be
physician. used to decrease
mucus and to improve
respiration.

 Provide supplemental  Humidity helps reduce

humidification like viscosity of secretions,
nebulizer. facilitating
expectoration, and may
reduce or prevent
formation of thick
mucus plugs in
bronchioles.