V.

Nursing Care Plan

NURSING CARE PLAN 1

ASSESSMENT DIAGNOSIS OUTCOME PLANNING NURSING INTERVENTION EVALUATION

Subjective: Ineffective At the end of Short Term INDEPENDENT Short Term:At the end
“ Halos isang buwan breathing pattern nursing At the end of 5hrs of  Position the patient in high fowler of 5hrs of nursing
na po akong related to impaired intervention, the nursing intervention, position. intervention, the client
nahihirapang gas exchange as patient will have the client will be able Rationale: To encourage oxygenation, and was be able to maintain
huminga at evidenced by an adequate to maintain an optimal promote lung expansion. an optimal breathing
naninikip po ang shortness of oxygen intake and breathing pattern, as pattern, as evidenced by
aking dibdib ” as breathing, chest will display a evidenced by  Teach the patient pursed-lip breathing. respiratory rate of 26
verbalized by the tightness, regular breathing respiratory rate of 26 Rationale: Controlled ventilation is possible with bpm relaxed breathing.
patient. wheezing, pattern. bpm relaxed pursed-lip breathing. Through pursed lips, the And above 95% of 02
cyanosis, pale, breathing.And above breath is slowly exhaled after being inhaled
Objective: sweaty face and 95% 0f 02. through the nose, providing for a longer
respiratory rate of expiration. Goal was met
 Irregular 26bpm and 90% of Long Term
breathing 02. At the end of 2 days  Encourage coughing exercises. Long Term:
(26cpm) nursing intervention, Rationale: Encouraging the patient to mobilize At the end of 2 days
 Wheezing the client will be able their own secretions via effective coughing nursing intervention, the
upon to establish normal facilitates adequate clearance of secretion. client was able to
inspiration breathing pattern. establish normal
and  Stay with the patient during acute breathing pattern.
expiration episodes of respiratory distress.
 Cyanosis Rationale: This will reduce the patient’s anxiety, Goal was met
 Pale, sweaty thereby reducing oxygen demand.
face
 Encourage frequent rest periods, and
V/S teach the patient to pace activity.
RR: 26 bpm Rationale: Extra activity can worsen shortness of
SpO2: 90% breath.
BP: 100/80 mmHg
T: 37.5  Encourage warm fluid intake
Rationale: Warm fluid intake can cause dilation
of the airway

 Auscultate breath sounds at least every

four hours.
Rationale: This is done in order to hear irregular
or diminished breath sounds. Auscultation also
aids in determining the bronchial tree's airflow
and determining if a lung obstruction is made of
solid or fluid.

DEPENDENT
 Administer oxygen via nasal cannula as
prescribed at the lowest concentration
Rationale: High concentration of oxygen hypoxia
triggers the drive to breath in the chronic Co2
retainer patient.

 Provide supplemental humidification

(ASTHALIN) as prescribed.
Rationale: Is used to prevent and
treat wheezing and shortness of breath caused
by breathing problems.

COLLABORATIVE
  Consult a dietician for dietary
modifications .
Rationale: Asthma may cause malnutrition which
can affect breathing patterns. Good nutrition can
strengthen the functionality of respiratory
muscles

NURSING CARE PLAN 2

NURSING
ASSESSMENT OUTCOME PLANNING NURSING INTERVENTION EVALUATION
DIAGNOSIS
Subjective: Ineffective airway At the end of nursing Short term: Independent: Short term: At the end
“Nahihirapan akong clearance related to intervention, the client At the end of 5hrs of nursing  Position the client in a of 5hrs of nursing
huminga at dyspnea as will be able to intervention, the patient will high Fowler’s position. intervention, the patient
naninikip po ang evidenced by demonstrate normal be able to improve and Rationale: High Fowler position was be able to improve
dibdib ko” as wheezing, breathing pattern and maintain airway patency by is also used for individuals with and maintain airway
verbalized by the shortness of breath, maintain airway patency. decreasing respiratory breathing difficulties as it pulls patency by decreasing
patient. ineffective distress as evidenced by down the diaphragm and relaxes respiratory distress as
coughing, chest respiratory rate of 26bpm abdominal respiratory muscles, evidenced by respiratory
Objective: tightness, to 18-20bpm and increasing allowing maximum chest rate of 26bpm
restlessness and SpO2 to 95% expansion and improvement of to 18-20bpm and
 Shortness of respiratory rate of breathing. increasing SpO2 to 95%
breath 26 bpm.
 Ineffective Long term:  Instruct the client to
coughing At the end of 2 days of perform diaphragmatic Goal was met
 Wheezing upon nursing intervention, the and pursed-lip breathing.
auscultation patient will able to Rationale: Pursed-lip breathing, Long term: At the end
 Chest demonstrate behaviors to diaphragmatic breathing, and of 2 days of nursing
tightness improve airway clearance as controlled breathing also improve intervention, the patient
 Restlessness evidenced by normal breath oxygenation, slow the respiratory was able to demonstrate
sounds and show no signs of rate, increase tidal volume, behaviors to improve
V/S respiratory distress decrease air trapping, and reduce airway clearance as
RR: 26 bpm the work of breathing. evidenced by normal
SpO2: 89%  Ensure a well-ventilated breath sounds and show
room for the client and no signs of respiratory
keep environmental distress
pollution to a minimum.
Rationale: Avoiding Goal was met
environmental stimuli that can
irritate the airways and create
breathing difficulties.
  Assist with measures to
improve effectiveness of
cough effort by strategic
clapping on the chest or
back.
Rationale: To assist in the
efficient removal of mucus from
the lungs by loosening and
expectorating excess secretions.
Coughing is more effective when
performed upright.

 Monitor vital signs and

oxygen saturation level.

Rationale: it can show whether

your heart and lungs are supplying
enough oxygen to vital organs –
including your brain.

 Educate the client on how

to avoid asthma triggers.
Rationale: In the self-
management of asthma and the
avoidance of acute exacerbations,
it is critical to avoid triggers such
as recognized allergens,
environmental temperature
extremes, chemical products, and
odors.
Dependent:
 Administer oxygen via
nasal cannula and
humidification therapies as
ordered.

Rationale: To increase oxygen

level
Humidification therapies can
help relax your lungs and airways
when they are tight.

 Administer budecort
(inhaler) as ordered
Rationale: It is used to prevent
the occurrence of asthma in
children aged 1 to 8 years.
Budecort respules should always
be administered with the help of
nebulizers.
NURSING CARE PLAN 3