HOLY NAME UNIVERSITY

College of Health Sciences

Department of Nursing
Tagbilaran City, Bohol

NURSING CARE PLAN

Name of Patient: _Karl___________________________________ Age: ___42_____________________ Status: ______Married________________________________
Address: ____________________________________________________ Date: ____________________ Ward: __________________________ Bed No: ___________________
Impression: ______________________________________________________________________________________________________________________________________

ASSESSMENT/ DIAGNOSIS PLANNING INTERVENTION

PROBLEM CUES/NRSG. DX RATIONALE OF THE DESIRED BEHAVIORAL NURSING RATIONALE EVALUATION
PROBLEM OUTCOME(S) OUTCOME(S) INTERVENTIONS
Subjective cues: Pneumonia can affect After 3 days of After 8 hours of Independent: Goal met:
Mr. Karl Verbalized people of all ages. The continuous intervention, the The patient was
shortness of breath infection causes the lungs' intervention the patient will be able - Assess cough - Coughing is the able to identify
air sacs to become patient will be able to: effectiveness and most effective way to methods to
inflamed and fill up with to: -demonstrate productivity remove secretions. enhance secretion
fluid or pus. -identify methods to behaviours to Pneumonia may removal and avoid
Swelling and mucus can enhance secretion achieve air way cause thick and specific factors that
make it harder to move air removal clearance tenacious secretions inhibit effective
through the airways, -identify and avoid -maintain a patent in patients. airway clearance
making it harder to specific factors that airway with breath then also
breathe. That can make it inhibit effective sounds clearing. - Suction as indicated: -Stimulates cough or demonstrate a
hard for the oxygen you airway clearance. frequent coughing, mechanically clears patent airway
breathe in to get into your adventitious breath airway in a patient clearance.
bloodstream, this leads to sounds, desaturation who cannot do so
shortness of breath, related to airway because of ineffective Goal not met:
difficulty breathing and secretions. cough or decreased
feeling more tired than level of The patient wasn’t
normal. consciousness. able to avoid
- Encourage - Helps mobilize specific factors that
ambulation. secretions and inhibits effective
 reduces atelectasis. airway clearance
and not able to
- Increasing the maintain patent
humidity will airway clearance.
- Use humidified decrease the viscosity
oxygen or humidifier of secretions. Clean
at the bedside. the humidifier before
use to avoid bacterial
growth
Dependent:
- Administer - Mucolytics increase
medications, as or liquefy respiratory
indicated secretions.,
expectorants
- increase productive
cough to clear the
airways by liquefying
lower respiratory
tract secretions and
reducing their
viscosity,
bronchodilators are
medications used to
facilitate respiration
by dilating the
airways, and
analgesics are given
to improve cough
effort by reducing
discomfort but
should be used
cautiously because
they can decrease
cough effort and
 depress respirations.

- Assist with - Bronchoscopy is

bronchoscopy and occasionally needed
thoracentesis, if to remove mucous
indicated. plugs, drain purulent
secretions, and
obtain lavage
samples for culture
and sensitivity and
thoracentesis is done
to drain associated
pleural effusions and
prevent atelectasis.

Objective Cues:
He is anxious because he
has HIV and pneumonia
and his wife is cheating on
him.
He complains shortness of
breath, fever and fatigue
Nursing Diagnosis:
Ineffective Airway
Clearance as related to
pneumonia as evidence by
shortness of breath.