Nursing

Care Plan:

1-Subjective

Assessment Nursing Diagnosis Goals Nursing Orders/Interventions Rationale Outcome criteria
/Evaluation

2-Objective

Subjective
Subjective data data:

Ineffective After 8h of Elevate Head of bed and Position

To maintain airway After 8h of nursing

is information :

(Symptoms) nursing appropriately.

provided
is by a
information Breathing intervention, intervention, the Patient
was maintains an
provided abynurse,
patient to Pattern related
a the Patient will

include the reason maintains an effective breathing

patient to a nurse, Assess and record respiratory rate To detect early

to hypoxia
the patient came
include the reason
as effective and depth at least every 4 hours. signs of respiratory

pattern, as evidenced
to a by relaxed breathing at
the evidence by
patient,andcame
breathing compromise.
normal rate and depth

healthcare pattern, as

shortness of
to a healthcare,
concerns, feelings.
evidenced by and absence of
and concerns, Beta-adrenergic

breath. relaxed dyspnea.

feelings.

breathing at Provide respiratory medications agonist medications

and oxygen, per doctor’s orders.

Objective data :
normal rate cause bronchodilation
is information and depth and to open air passages
Objective data

observed
(Signs) :
through absence of

Suctioning helps to
your
is senses of
information dyspnea.
Suction secretions, as necessary. clear the blockages
hearing,
observed sight,
through
smell, and touch
your senses of

in the airway.

while assessing
Ambulation can
hearing, sight, Ambulate patient as tolerated with
the patient.
smell, and touch
while assessing
doctor’s order three times daily.
further break up and
move secretions that

block the airways.

the patient.
Educate patient on proper breathing, allow sufficient
coughing Methods. mobilization of
secretions.