NURSING CARE PLAN

Patient: Mrs. K Age: 68 Diagnosis: Community Acquired Pneumonia

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Ineffective airway After 4 hours of  Established rapport  To gain trust After 4 hours of
clearance related nursing intervention, nursing
“inuubo ako,nahihirapan
to excessive the patient will be able intervention,the
akong huminga”as
mucus. to demonstrate  Monitored the vital  To have baseline patient was able
verbalized
behaviors to improve signs data to demonstrate
or maintain clear behaviors and
OBJECTIVE: airway. reduced mucus
 Assessed behavior  This information is on airway.
Vital Signs: indicating respiratory essential for
distress as well as identifying potential
BP: 110/70
level of for airway GOAL
CR: 83 consciousness and problems,providing PARTIALLY MET
RR: 23 ability to protect own baseline level of
airway care needed.
Temp: 37

 Monitored respirations  Indicative of

+Abnormal `respiratory and breath respiratory distress
rate, rhythm, and depth` sounds,noting rate and/or accumulation
+ DOB and sounds of secretions

 Evaluated client`s
cough/gag  To determine ability
reflex,amount and to protect own
type of secretions,and airway
swallowing activity

 Administered  To relax smooth

medication respiratory
musculature,
reduced airway

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 edema, and mobilize
secretion.

 Auscultated breathing
 To ascertain current
sound and assess
status and note
airway movement
effects of treatment
clearing airways

 Changed client’s
position every 2 hours  To take advantage
of gravity decreasing
pressure on the
diaphragm
 Increased fluid intake
to at least 2,000  Hydration can help
mL/day within cardiac prevent the
tolerance accumulation of
viscous secretions
and improve
secretion clearance
 Observe for signs and
symptoms of infection  To identify the
infectious process
and promote timely
intervention

 Exercise diligence in
 Airways can be
providing oral hygiene
obstructed by
and keeping oral
substance such as
mucosa hydrated
blood or thickened
secretion

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