Nursing Care Plan

Nursing Scientific Nursing

Cues Objectives Rationale Evaluation
Diagnosis Rationale Interventions
Subjective: Ineffective Common to many After 8 hours of 1. Establish It allows you to After 8 hours of
 “Sige kasi Airway pulmonary nursing rapport with understand your nursing
iton an Clearance related diseases intervention, pt and SO patient and SO's intervention,
paginubo ni patient will be feelings and
to increased is bronchospasm patient was able
baby nga able to: communicate
mayda ba production of that reduces the well with them. to:
plema ngan secretions caliber of the  maintain
hin nagkukuri small bronchi and airway 2. Assess airway Maintaining  maintain
hiya pag may cause patency with for patency. patent airway is airway
hinga”, as difficulty in breath sounds always the first patency with
verbalized. breathing, stasis clear/clearing priority, breath sounds
 “Maiha adto  demonstrate especially in
of secretions, and clear/clearing
na iya behaviors to cases like trauma,
infection. improve acute evidence by
paginubo kay
han syahan airway neurological normal breath
nagpa check- clearance decompensation, sounds,
up kami ngan 3. Assess or cardiac arrest. normal rate
katapos gin respirations. and depth of
resetahan hiya Note quality, A change in the
respirations,
hin antibiotic rate, pattern, usual respiration
may mean and normal
na co- depth, flaring
amoxiclav tas respiratory O2 saturation
of nostrils,
waray man dyspnea on compromise. An
 demonstrate
kaupay asya exertion, increase in
respiratory rate behaviors to
gin pa admit evidence of
na hiya didi,”, and rhythm may improve
splinting, use
as verbalized be a airway
of accessory
 “Dida han nag muscles, and compensatory clearance

Dames, Jan Remedios B – Clinical Group D | Nursing Care Plan

 iinubo hiya, position for response to
nagkukuri na breathing. airway GOALS WERE
ak pag pakaon obstruction. MET.
ha iya pero 4. Note for
yana nag balik changes in
na an iya gana HR and Increased work of
pag kaon”, as temperature. breathing can lead
verbalized to tachycardia and
hypertension.
Objective: Retained
 Productive secretions or
cough atelectasis may be
 Crackles upon a sign of an
inspiration existing infection
 Pale lips or inflammatory
 With process
wheezing manifested by a
fever or increased
5. Note cough temperature.
for efficacy
and Coughing is a
productivity. mechanism for
clearing
secretions. An
ineffective cough
compromises
airway clearance
and prevents
mucus from being
expelled.
Respiratory
muscle fatigue,

Dames, Jan Remedios B – Clinical Group D | Nursing Care Plan

 severe
bronchospasm, or
thick and
tenacious
secretions are
6. Use pulse possible causes of
oximetry to ineffective cough.
monitor
oxygen Pulse oximetry is
saturation; used to detect
assess arterial changes in
blood gases oxygenation.
(ABGs). Oxygen
saturation should
be maintained at
90% or greater.
Alteration in
ABGS may result
in increased
pulmonary
7. Place the secretions and
patient in a respiratory
semi fowler’s fatigue.
position or
elevate head. Upright position
limits abdominal
contents from
pushing upward
and inhibiting
lung expansion.
This position
promotes better
8. Monitor for

Dames, Jan Remedios B – Clinical Group D | Nursing Care Plan

 the risk of lung expansion
aspiration.  and improved air
exchange.

Should they
aspirate on their
secretions this
will put them at a
significantly
increased risk for
aspiration
9. Administer pneumonia,
medications, which would
as ordered: further impair gas
a. Salbutamo exchange and
l 1 neb respiratory
q8H failure.
b. Budesonid
e 1 neb Nebulizer
q12H treatment may be
c. Ceftriaxon administered
e 840 mg to help loosen the
as IV drip mucus in your
to run for lungs and help
30 breathe better.
minutes Antibiotic
treatment may be
given, as well.

Dames, Jan Remedios B – Clinical Group D | Nursing Care Plan

 Nursing Scientific Nursing
Cues Objectives Rationale Evaluation
Diagnosis Rationale Interventions
Subjective: Impaired gas Lung function After 8 hours of 1. Establish It allows you to After 8 hours of
 “Sige kasi exchange related abnormalities nursing rapport understand your nursing
iton an to related to both at rest and intervention, patient and SO's intervention,
paginubo ni patient will be feelings and
alveolar-capillary during exercise patient was able
baby nga able to: communicate well
mayda ba gas diffusion are frequently with them. to:
plema ngan imbalance observed in  Show signs of
hin nagkukuri patients with improved gas 2. Assess Rapid and  Show signs of
hiya pag exchange respiratory shallow breathing improved gas
chronic
hinga”, as  show rate, depth, patterns and
respiratory exchange as
verbalized. improved and effort, hypoventilation
disease. including the evidenced by
 “Maiha adto status of affect gas
use of oxygen
na iya breathing. exchange
accessory saturation
paginubo kay
han syahan SO will: muscles, nasal within normal
nagpa check-  verbalize flaring, and range,
up kami ngan understanding abnormal absence or
katapos gin health breathing
diminished
resetahan hiya teachings in patterns.
use of
hin antibiotic appropriate
ways of 3. Assess the Any irregularity accessory
na co-
promoting gas lungs for of breath sounds muscles when
amoxiclav tas
exchange in areas of may disclose the breathing,
waray man
patient and decreased cause of impaired diminished
kaupay asya
importance of ventilation gas exchange. 
gin pa admit fatigability,
compliance to and auscultate
na hiya didi,”, and absence
treatment presence of
as verbalized or diminished
adventitious
 “Dida han nag
sounds. difficulty of
iinubo hiya,
nagkukuri na breathing
4. Monitor Changes in

Dames, Jan Remedios B – Clinical Group D | Nursing Care Plan

 ak pag pakaon patient’s behavior and  show
ha iya pero behavior and mental status can improved
yana nag balik mental status be early signs of status of
na an iya gana for the onset impaired gas
breathing.
pag kaon”, as of exchange.
verbalized restlessness,  Verbalize
agitation, understanding
Objective: crying, health
 Productive confusion, teachings in
cough and (in the appropriate
 Crackles upon late stages) ways of
inspiration extreme
promoting gas
 Pale lips lethargy.
 With BP, HR, and exchange in
wheezing 5. Monitor for respiratory rate all patient and
alteration in increase with importance of
BP and HR. initial hypoxia
compliance to
and hypercapnia
treatment
Central cyanosis
6. Observe for of tongue and oral GOALS WERE
nail beds, mucosa indicates MET.
cyanosis in severe hypoxia
the skin; and is a medical
especially emergency
note the color
of the tongue
and oral
mucous
Pulse oximetry is
membranes.
a useful tool to
7. Monitor detect changes in
oxygen oxygenation.

Dames, Jan Remedios B – Clinical Group D | Nursing Care Plan

 saturation
continuously,
using a pulse
oximeter.
Increasing PaCO2
8. Note blood and decreasing
gas (ABG) PaO2 are signs of
results as respiratory
available and acidosis and
note changes hypoxemia

Upright or semi-
9. Position Fowler’s position
patient with allows increased
head of the thoracic capacity,
bed elevated, total descent of
in a semi- the diaphragm,
Fowler’s and increased
position (head lung expansion
of the bed at preventing the
45 degrees abdominal
when supine) contents from
as tolerated. crowding.
Ambulation
facilitates lung
expansion,
secretion
clearance and
stimulates deep
breathing.

Nebulizer
10. Administer
treatment may be

Dames, Jan Remedios B – Clinical Group D | Nursing Care Plan

 medications, administered to
as ordered: help loosen the
d. Salbutamo mucus in your
l 1 neb lungs and help
q8H breathe better.
e. Budesonid Antibiotic
e 1 neb treatment may be
q12H given, as well.
f. Ceftriaxon
e 840 mg
as IV drip
to run for
30
minutes

Dames, Jan Remedios B – Clinical Group D | Nursing Care Plan

 Nursing Scientific Nursing
Cues Objectives Rationale Evaluation
Diagnosis Rationale Interventions
Subjective: Risk for Pneumonia is an After 8 hours of 10. Establish It allows you to After 8 hours of
 “Sige kasi infection related infection itself but nursing rapport understand your nursing
iton an to presence of a risk for intervention, patient and SO's intervention,
paginubo ni patient will be feelings and
existing infection infection nursing patient was able
baby nga able to: communicate well
mayda ba diagnosis is with them. to:
plema ngan appropriate as  Show signs of
hin nagkukuri untreated worsening or 11. Assess Rapid and  Show signs of
hiya pag impending respiratory shallow breathing worsening or
pneumonia can
hinga”, as infections rate, depth, patterns and
progress into a impending
verbalized.  display and effort, hypoventilation
secondary including the infections
 “Maiha adto improvement affect gas
infection use of  display
na iya in infection exchange
or sepsis. evidenced by accessory improvement
paginubo kay
han syahan vital signs and muscles, nasal in infection
nagpa check- physical flaring, and evidenced by
up kami ngan condition abnormal vital signs and
katapos gin breathing
physical
resetahan hiya SO will: patterns.
condition
hin antibiotic  verbalize
understanding 12. Assess the Any irregularity  SO was able
na co-
on health lungs for of breath sounds to verbalize
amoxiclav tas
teachings areas of may disclose the understanding
waray man
regarding decreased cause of impaired on health
kaupay asya
importance ventilation gas exchange. 
gin pa admit teachings
and how to and auscultate
na hiya didi,”, regarding
prevent presence of
as verbalized importance
infection adventitious
 “Dida han nag
sounds. and how to
iinubo hiya,
nagkukuri na prevent
13. Monitor Changes in

Dames, Jan Remedios B – Clinical Group D | Nursing Care Plan

 ak pag pakaon patient’s behavior and infection
ha iya pero behavior and mental status can
yana nag balik mental status be early signs of GOALS WERE
na an iya gana for the onset impaired gas MET.
pag kaon”, as of exchange.
verbalized restlessness,
agitation,
Objective: crying,
 Productive confusion,
cough and (in the
 Crackles upon late stages)
inspiration extreme
 Pale lips lethargy.
 With Dropping blood
wheezing 14. Monitor for pressure,
worsening hypothermia
signs of or hyperthermia,
infection elevated heart
rate, and
tachypnea are
signs of sepsis
that require
immediate
attention.

15. Assess lab An elevated white

values. blood count is
indicative of
infection. This is
an expected
finding with
pneumonia, but
should not

Dames, Jan Remedios B – Clinical Group D | Nursing Care Plan

 continue to rise
with treatment. If
sepsis is
suspected, a blood
culture can be
obtained.
16. Consider
sources of Any inserted lines
infection. such as IVs,
urinary catheters,
feedings tubes,
suction tubing, or
ventilation tubes
are potential
sources of
infection.
Remove
unnecessary lines
as soon as
possible. Surgical
incisions and any
skin breakdown
should be
monitored for
redness, warmth,
17. Encourage drainage, or odor
fluid intake that signals an
and nutrition. infection.

Hydration is vital
to prevent
dehydration and

Dames, Jan Remedios B – Clinical Group D | Nursing Care Plan

 supports
homeostasis.
Fluids help the
kidneys filter and
flush waste
products
preventing renal
and urinary
infections.
Encouraging oral
fluids will
18. Promote skin mobilize
integrity. respiratory
secretions. Proper
nutrition
promotes energy
and supports the
immune system.

The skin is the

body’s first
barrier against
infection. Skin
breakdown allows
pathogens to enter
the body. If a
patient is
immobile they
must be
11. Administer repositioned
medications, every 2 hours to
as ordered: maintain skin
g. Salbutamo

Dames, Jan Remedios B – Clinical Group D | Nursing Care Plan

 l 1 neb integrity. Keep
q8H skin clean and dry
h. Budesonid through frequent
e 1 neb perineal care or
q12H linen changes.
i. Ceftriaxon
e 840 mg Nebulizer
as IV drip treatment may be
to run for administered to
30 help loosen the
minutes mucus in your
lungs and help
breathe better.
Antibiotic
treatment may be
given, as well.

Dames, Jan Remedios B – Clinical Group D | Nursing Care Plan