CALMA, Mary Ann C.

BSN – IV-LEININGER
Skill: Breathe Comfortably Nursing Care Plan
Complete the nursing care plan based on the stated nursing intervention on a client with acute respiratory condition. Some in tervention may be added like,
administering mucolytic but remain focus on the skill from the course outline. Point: 3 points per column. First table refers to effective NCP and 2nd table for
ineffective NCP r/t to the acute respiration condition. Remember the case #2 from the discussion where the case description is “The patient was a 66-year-old
man who was admitted to an ICU for acute respiratory failure”. Add some modification in intervention as the given one is onl y the title
Nursing Care Plan 1

Assessment Nursing diagnosis Plan Intervention Evaluation

Actual At the end of Goal met – good sign /
Cues ⮚ Impaired gas The client will ⮚ Chest symptoms
Subjective exchange ⮚ Participate in physiotherapy
⮚ Dyspnea related to treatment regimen techniques (20 – 40 Objective
⮚ Hypoxia increased such as effective minutes) to ⮚ Regular pulse
alveolar- coughing within promotes optimal rate of the client
⮚ Severe abdominal
capillary level of ability chest expansion ⮚ Decreased
pain
permeability, and drainage of
⮚ Expectorate respiratory rate
interstitial secretions
thickened mucus
Objective edema, and ⮚ Monitor the ⮚ Can be able to
⮚ Thick mucus secretions
decreased lung oxygen saturation have effective
secretions compliance. ⮚ Establish a (O2 Sat) coughing within
⮚ Productive cough normal/effective level of ability
⮚ Ineffective ⮚ Maintain adequate
⮚ Moderate respiratory pattern
breathing I/O for
pneumothorax (20%) pattern mobilization of
on the right side secretions
⮚ Ineffective
⮚ Increased respiratory airway ⮚ Reinforce need for
rate (28 to 30bpm) clearance adequate rest to
⮚ Irregular pulse rate decrease dyspnea
(110 bpm) and improve
Risk
quality of life
⮚ Risk for
⮚ Restlessness
aspiration ⮚ Encourage position
of comfort.
Reposition client
⮚ I/O: 200 cc from 7:30 State below the frequently if
AM to 2:30 PM background knowledge immobility is a
factor
⮚ Take a steaming
hot shower or hold
your head over a
steaming pot of
water to help thin
mucus and make it
easier to expel
Collaboration:
 Administer
mucolytic as
prescribed by the
physician
Goal un met - poor s/s
Subjective cues
⮚ “Masakit ang
dibdib ko” as
stated by the
client

⮚ Dyspnea
⮚ hypoxia
Objectives cues
⮚ The thickened
mucus secretions
cannot
expectorate all
properly
⮚ Productive cough
due to remaining
mucus
 ⮚ Decrease oxygen
saturation (90%)

Nursing Care Plan 2

Assessment Nursing diagnosis Plan Nursing Intervention Evaluation
Goal un met Actual At the end of ⮚ Surgical Insertion Goal met
⮚ Impaired gas The client will of tracheostomy
Subjective cues exchange related ⮚ Participate in ⮚ Tracheostomy Subjective cues
⮚ “Masakit ang to increased treatment care ⮚ Cannot be able to
dibdib ko at alveolar-capillary regimen such as experience Dyspnea
parang gasgas na permeability, use of oxygen
⮚ Cannot be able to
ang lalalamunan interstitial edema, within level of
experience Hypoxia
ko” as stated by and decreased ability
the client lung compliance. ⮚ Participated in
⮚ Maintain airway
treatment regimen
⮚ Dyspnea (feeling ⮚ Ineffective airway patency
such as use of oxygen
of breathlessness) clearance related
⮚ Reduce mucus within level of ability
⮚ hypoxia to retained
secretions
secretions ⮚ Maintained airway
Objectives cues patency
⮚ The thickened Risk
mucus secretions Objective cues
 Risk for activity ⮚ Oxygen saturation of
cannot intolerance
expectorate all 97%
 Risk for impaired
properly integrity ⮚ Mucus secretions are
⮚ Productive cough
not thickened but
due to remaining
steamed so that it can
mucus
expectorate through
⮚ Decrease oxygen the tracheostomy
saturation (90%) tube

⮚ Left lower lobe ⮚ Not experiencing

collapse due to deep coughing
mucus plugging
⮚ Respiratory rate are
normal
 (as seen on Chest ⮚ Pulse rate becomes
X-Ray) regular
⮚ Small left sided
pleural effusion
(as seen on Chest
X-Ray)