MCN Form 016

Lyceum of the Philippines University

College of Nursing

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective:
● Ineffective Airway ● After 4 hours of ● Note presence and ● Cough that is ● After 4 hours of
“Nahihirapan pa rin syang Clearance related to nursing interventions, character of cough. persistent and nursing interventions,
huminga dahil ng plema” as inability to maintain the patient will display ● Monitor vital signs, constant can interfere the patient was able
verbalized by the mother clear airway as patent airway with especially respiratory with breathing to display patent
characterized by (+) breath sounds rate ● With secretions in the airway with breath
Objective: sputum, (+) crackles, clearing and absence ● Observe airway, the respiratory sounds clearing and
rapid & shallow of tachypnea characteristics of rate will increase absence of tachypnea
- Use of accessory breathing breathing pattern. ● May see use of
muscles when ● Auscultate and accessory muscles for
breathing percuss chest, breathing.
- Presence of describing presence, ● Abnormal breath
productive cough absence, and sounds are indicative
- Tachypnea character of breath of numerous
- Sputum production sounds. problems and must be
● Elevate head of the evaluated further.
➢ Vital signs as follows: bed, change position ● Lowers diaphragm,
● T: 36.0°C frequently promoting chest
● PR: 97 bpm ● Force fluids to at least expansion and
● RR: 36 bpm 3000 ml per day and expectoration of
● BP: 90/60 offer warm, rather secretions.
● O2Sat: 99% than cold fluids. ● Fluids especially
warm liquid aids in
mobilization and
expectoration of
secretions
 MCN Form 016

Lyceum of the Philippines University

College of Nursing