A Case of:

Ineffective airway breathing related to mucus obstruction as

evidenced by dyspnea.

Presented by:
Penaranda, Andrea Karl C.

Presented to/Submitted to:

Ms. Jocelyn Quiboloy

Submitted on:
November 9, 2023
NURSING CARE PLAN
CUES NURSING ANALYSIS GOAL INTERVENTI RATIONALE EVALUATION
DIAGNOSIS ON

Subjective Disturbed Sleep Scientific Short term: Observation and

Cues: Pattern related Analysis: Within an hour Assessment
As verbalized to of nursing
by the client environmental Sleep is essential intervention the
"Noong wala factors (e.g., for maintaining client will be
pa ako dito, unfamiliar healthy systemic able to:
5am palang room, noise, physiology
gising na ako lighting) as throughout the Cognitive
para mag- evidenced by body, including 1. The patient 1. Having enough The patient
prepare sa frequent the brain. Sleep will be able to 1.Understanding sleep is crucial learned about the
school then awakenings and issues, which comprehend or the risk of not role to increase the significance of
makakatulog na difficulty falling affect both understand having enough cognitive skills having enough
ako ay mga asleep amount and various crucial sleep and the and having a good sleep
9pm” quality of sleep, elements to risk of sleep memory, while not
are quite address and interruptions having enough ▢ Met
“4 to 5 hours common; they control the sleep sleep may affect ▢ Unmet
nalang ang are referred to as disturbances. physical and
pinaka matagal sleep cognitive health of
ko na tulog, interruptions students and their
pero may nap when they academic
time din doon” interfere with a performance
person's ability to (Maheshwari &
Hindi ko na sleep Shaukat, 2019).
kumpleto ang 8 continuously.
hours na tulog (Medic et al.,
dahil pa-gising 2017).
gising din ako”
 Situational Affective 2. Comfortable
Analysis: 2. Understanding 2. Determining sleeping will give The patient
Objective of having a if the patient is a well-rested understand the
cues: The client comfortable aware of the experience and advantages of
verbalizing of sleeping advantages of less daytime of having a
She appears getting up early environment and having a sleepiness and comfortable sleep
tired, weak, and at 5am when she reduce of comfortable fatigue. It will
have dark circle was not admitted distraction that sleep make people more ▢ Met
spots under her to the hospital causes the productive and can ▢ Unmet
eyes. and she sleeps at patient to wake concentrate better
9pm that will up by verbalizing in studies
give her an 8 it and verbalizing (Harvard Summer
hours of sleep. of feeling rested School, 2021).
As she was
admitted to the
hospital she
sleeps at only 4 Psychomotor
to 5 hours 3. The patient 3. The patient 3. The
including her nap can now will be able to environment can 3.The patient
time. She does demonstrate demonstrate have an impact on demonstrated
not complete her different consistent sleep patterns, consistent sleeping
8 hours anymore behaviors and sleeping particularly in a patterns and no
because of changes in patterns and no hospital setting nigh time
interruptions of sleeping routine nigh time where there is awakenings
waking up and be well awakenings constant noise,
suddenly. rested, evidenced ligt, regular ▢ Met
by having 7 to 9 monitoring, and ▢ Unmet
hours of sleep. therapy. Not
getting enough
sleep might have
instant negative
effects. (Wayne,
 2019).

References:

Harvard Summer School. (2021, May 28). Why you should make a good night’s sleep a priority. Harvard Summer School.

https://summer.harvard.edu/blog/why-you-should-make-a-good-nights-sleep-a-priority/

Maheshwari, G., & Shaukat, F. (2019). Impact of Poor Sleep Quality on the Academic Performance of Medical Students. Cureus, 11(4).

https://doi.org/10.7759/cureus.4357

Medic, G., Wille, M., & Hemels, M. (2017). Short- and long-term Health Consequences of Sleep Disruption. Nature and Science of Sleep,

9(9), 151–161. https://doi.org/10.2147/nss.s134864

Wayne, G. (2019). Insomnia – Nursing Diagnosis and Care Plan. Nurseslabs. https://nurseslabs.com/insomnia/
NURSING CARE PLAN
CUES NURSING ANALYSIS GOAL INTERVENTI RATIONALE EVALUATION
DIAGNOSIS ON
Subjective Ineffective Scientific Short term: Observation and
Cues: airway Analysis: Within an hour Assessment
As verbalized breathing of nursing
by the client’s related to Breathing intervention the Effectiveness:
mother “Yung mucus difficulties can patient will be
anak ko ang obstruction as be caused by able to: Independent:  Through ● Was the goal
bilis huminga evidenced by excess of mucus  Monitor the including the three
at masyadong dyspnea. in the lungs,  Indicate and do trachea- objectives
marinig yung which narrows improved vital bronchial achieved? If not,
paghinga nya the airways. clearing signs by tree, why?
nag-aalala na Infections like of the auscultat auscultatio
ako sakanya pneumonia can airways ing for n evaluates ● Was the client
kaya tinakbo ko also result from with less assessin airflow. To state of health has
na sa hospital increased mucus mucus g breath make the improved
tapos ay in the lungs. discharge sounds right
nagkalagnat din s or diagnosis, Efficiency:
sya kagabi pati Wagner, M. blockage it's critical
ngayon” (2022, February of the to ● Was the
9). Pneumonia airways.  Evaluate differentiat approach
Nursing client’s e between employed suitable
Objective Diagnosis &  Patient cough normal and and appropriate
cues: Care Plan. will and atypical for the time
NurseTogether. maintain improve respiratory provided?
The baby have https://www.nurs a patent ment of sounds,
audile etogether.com/pn airways breathin such as
breathing eumonia- g crackles,
sounds, fast nursing- patterns wheezes,
breathing, has a diagnosis-care-  Patient  Encoura and pleural Adequacy:
fever and looks plan/ will have ge rub.
tired relaxed patient ● Was the exact
Situational breathing on Sarkar, M., learning objectives
Analysis: pattern drinking Madabhavi, I., and content
lots of Niranjan, N., & sufficient to meet
When the patient fluids Dogra, M. (2019). the patient's
was not admitted Long term Auscultation of demands?
to the hospital, Goal: the respiratory
the mother of the After 1 week of system. Annals of Met
patient said she nursing Thoracic Unmet
got up early at intervention the Medicine, 10(3),
three in the patient will be 158–168. ● Was the
morning because able to https://doi.org/10. learning aim
she had heard 4103/1817- offered to the
that the child was Cognitive 1737.160831 patient enough to
experiencing 1. The parents of Dependent: suit his or her
breathing the patient will  Adminis demands?
problems and verbalize the ter To improve the
had a high body understanding of medicati client's feelings Met
temperature. cause of having ons, and function Unmet
breathing such as physically; as well
difficulties of the antibioti as to improve Appropriateness:
child and have cs, sense of overall
knowledge of ipratropi well-being ● Was the
enhancing the um (Wagner, 2023). interventions
child’s breathing bromide selected suitable
pattern + for the needs of
sabutam the patient?
Affective ol
2. Display an Met
improvement in Collaborative: Unmet
breathing and  Refer
maintain clear the To keep the child ● Was the
airways patient safe, healthy and therapies chosen
to have a proper capable of
hospitals guidance of meeting the
or professional aids. patient's needs?
Psychomotor clinics
 3. Demonstrate with Blocher, M. Acceptability:
reduction of pediatric (2023, February
nasal congestion units to 6). Why Is ● Was the patient
provide Pediatric Care ready to
addition Important? |. participate and
al Christian follow the
professi Healthcare directions for the
onal aid. Centers, Inc. intervention?
https://www.chcen
ters.org/why-is- Met
pediatric-care- Unmet
important/

References:
Sarkar, M., Madabhavi, I., Niranjan, N., & Dogra, M. (2019). Auscultation of the respiratory system. Annals of Thoracic Medicine,
10(3), 158–168. https://doi.org/10.4103/1817-1737.160831
Wagner, M. (2022, February 9). Pneumonia Nursing Diagnosis & Care Plan. NurseTogether.
https://www.nursetogether.com/pneumonia-nursing-diagnosis-care-plan/
Blocher, M. (2023, February 6). Why Is Pediatric Care Important? |. Christian Healthcare Centers, Inc.
https://www.chcenters.org/why-is-pediatric-care-important/