NURSING CARE PLAN

Client’s Name: Date: Clinical Area of Assignment:

Cues/Evidences Nursing Diagnosis Outcome Criteria Nursing Intervention Rationale Evaluation
Independent:

 Akong ubo kay  Acute pain r/t After 4 hours of  Elevate head of the bed,  Lowers After 4 hours of
1 week na” as localized nursing interventions change position frequently diaphragm, nursing interventions,
verbalized by inflammation and the client will be able  Assist patient with deep promoting chest the patient was able to
the client. persistent cough to: breathing exercises expansion and display patent airway
 Demonstrate or help patient expectoration of with breath sounds
. display patent airway learn to perform activity like secretions. clearing and absence
with breath sounds splinting chest and effective of dyspnea.
Objective cues: clearing and absence of coughing while in upright
dyspnea position.
 Use of  Deep breathing
 Force fluids to atleast 3000
accessory facilitates
ml per day and offer warm,
muscle maximum
rather than cold fluids
 Dyspnea expansion of the
 Fatigue lungs and smaller
airways
 Vital signs:
T- 36°C
P-80 bpm
R- 20 cpm  Coughing is a
BP- 100/80 natural self-
mmHg cleaning
mechanism.
Splinting reduces
chest discomfort,
and an upright
position favors
 deeper, more
forceful cough
effort
 Fluids especially
warm liquid said
in mobilization
and expectoration
of secretions.
Submitted By: Name of CI: Date: _