NURSING CARE PLAN (INEFFECTIVE AIRWAY CLEARANCE)

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Ineffective airway After 3 hours of 1. Assess airway for patency. 1. Maintaining patent airway is GOAL MET.
- “nahihirapan clearance related rendering my always the first priority,
akong huminga at to infection nursing especially in cases like trauma, After 3 hours of
naninikip yung secondary to intervention the acute neurological rendering my
dibdib ko” as pneumonia as client will maintain decompensation, or cardiac nursing
verbalized by the evidence by clear, open airways arrest. intervention the
patient abnormal lung as evidence by client have
2. Auscultate lungs for presence of
sound (crackles) normal breath 2. Abnormal breath sounds can maintain clear,
normal or adventitious breath
Objective: sounds, respiration be heard as fluid and mucus open airways as
sounds
- Bilateral crackles and good oxygen accumulate. This may indicate evidence by normal
saturation. ineffective airway clearance. breath sounds,
- RR(49) -May 02, respiration and
3. Assess respirations. Note
2022, 7:30am 3. A change in the usual good oxygen
quality, rate, pattern, depth, flaring
respiration may mean saturation.
of nostrils, dyspnea on exertion
respiratory compromise. An
increase in respiratory rate and
rhythm may be a compensatory
response to airway obstruction.
4. Note for changes in mental
status. 4. Increasing lethargy,
confusion, restlessness, and/or
irritability can be initial signs
of cerebral hypoxia.
5. Note for changes in HR, BP, and
temperature. 5. Increased work of breathing
can lead to tachycardia
and hypertension. Retained
secretions or atelectasis may be
a sign of an
existing infection or
 inflammatory process
manifested by a fever or
6. Note cough for efficacy and increased temperature.
productivity.
6. Coughing is a mechanism
for clearing secretions. An
ineffective cough compromises
airway clearance and prevents
mucus from being expelled.
Respiratory muscle fatigue,
severe bronchospasm, or thick
and tenacious secretions are
7. Use pulse oximetry to monitor possible causes of ineffective
oxygen saturation cough.

7. Pulse oximetry is used to

detect changes in oxygenation.
8. Teach the patient the proper Oxygen saturation should be
ways of coughing and breathing. maintained at 90% or greater.

8. The most convenient way to

remove most secretions is
coughing. So it is necessary to
assist the patient during this
activity. Deep breathing, on the
other hand, promotes
9. Educate the patient in the
oxygenation before controlled
following:
coughing.
 Optimal positioning (sitting
position)
9. The proper sitting position
 Use of pillow or hand
and splinting of the abdomen
splints when coughing
promote effective coughing by
 Use of abdominal muscles
increasing abdominal pressure
 for more forceful cough and upward diaphragmatic
 Use of quad and huff movement. Controlled
techniques coughing methods help
 Use of incentive spirometry mobilize secretions from
 Importance of ambulation smaller airways to larger
and frequent position airways because the coughing
changes is done at varying times.
Ambulation promotes lung
expansion, mobilizes
10. Provide oxygen therapy secretions, and lessens
atelectasis.

10. Oxygen therapy is

recommended to improve
oxygen saturation and reduce
possible complications.

NURSING CARE PLAN (FATIGUE)

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Fatigue related to After 4 hours of 1. Assess the patient's degree of 1. To create a baseline of GOAL MET.
“ayoko na, pagod decreased rendering my fatigability by asking to rate his/her activity levels, degree of
na ako” as metabolic energy nursing fatigue level (mild, moderate, or fatigability, and mental status After 4 hours of
verbalized by the production as intervention the severe). Explore activities of daily related to fatigue and activity rendering my
patient evidenced by client will verbalize living, as well as actual and intolerance. Fatigue is a highly nursing
verbalization of ease of fatigue and perceived limitations to physical subjective symptom and there intervention the
Objective: tiredness demonstrate active activity. Ask for any form of is no gold standard tool in client verbalized
- irritable participation in exercise that he/she used to do or measuring a person's ease of fatigue and
necessary and wants to try. fatigability. demonstrate active
desired activities participation in
2. Encourage the patient to adhere 2. Low fat, low calories, and necessary and
to his/her dietary plan. high fiber foods are ideal for desired activities.
diabetic patients. Proper
 nutrition through healthy
dietary choices may reduce
fatigue levels.
3. Teach deep breathing exercises 3. To allow the patient to relax
and relaxation techniques. while at rest.
4. Refer the patient to 4. To provide a more
physiotherapy / occupational specialized care for the patient
therapy team as required. in terms of helping her build
confidence in increasing daily
physical activity.

NURSING CARE PLAN (INEFFECTIVE BREATHING PATTERN)

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Ineffective After 6 hours of 1. Assess and record respiratory 1. The average rate of GOAL MET.
- “nahihirapan breathing pattern rendering my rate and depth at least every 4 respiration for adults is 10 to
akong huminga at related infection nursing hours. 20 breaths per minute. It is After 6 hours of
naninikip yung secondary to intervention the important to take action when rendering my
dibdib ko” as community client will exhibit there is an alteration in nursing
verbalized by the acquired an effective breathing patterns to detect intervention the
patient pneumonia breathing pattern early signs of compromise on client exhibit an
with oxygenation the respiratory system. effective breathing
Objective: saturation, pattern with
- abnormal lung respiratory rate, 2. Evaluate skin color, temperature, 2. Lack of oxygen will cause oxygenation
sound (crackles) pulse rate within capillary refill. blue/cyanosis coloring to the saturation,
- RR (49) normal range lips, tongue, and fingers. respiratory rate,
- Restlessness Cyanosis to the inside of pulse rate within
- Patient assumes the mouth is a medical normal range
tripod position emergency.
- abnormal chest X-
 ray
- dyspnea 3. Place patient with proper body 3. A sitting position permits
- orthopnea
alignment for maximum breathing maximum lung excursion and
pattern. chest expansion.

4. Encourage sustained deep 4. These techniques promote

breaths. Techniques include (1) deep inspiration, which
using demonstration: highlighting increases oxygenation and
slow inhalation, holding end prevents atelectasis. Controlled
inspiration for a few seconds, and breathing methods may also aid
passive exhalation; (2) utilizing slow respirations in tachypneic
incentive spirometer and (3) patients. Prolonged expiration
requiring the patient to yawn prevents air trapping.

5. Encourage diaphragmatic 5. This method relaxes muscles

breathing for patients with chronic and increases the patient’s
disease. oxygen level.

6. Encourage small frequent meals. 6. This prevents crowding of

the diaphragm.

7. Educate patient or significant 7. These allow sufficient

other on proper breathing, mobilization of secretions.
coughing, and splinting methods.

NURSING CARE PLAN (FLUID VOLUME, EXCESS)

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Objective: Fluid volume After 2 days of 1. Assess the patient's vital signs 1. The measurement of the GOAL MET.
- edema excess related to rendering my regularly. patient's vital signs will help
- congestive heart compromised nursing evaluate the progress of After 2 days of
failure regulatory intervention the management. It will also rendering my
- dyspnea mechanism client will regained indicate if the patient's nursing
secondary to heart a balance breathing is improving. intervention the
failure as Fluid volume as client have
2. Weigh the patient on a daily 2. The patient's weight is one regained a balance
evidence by the evidence by ease of
basis Use the same scale. Use the clinical indicator of fluid Fluid volume as
presence of breathing, clear
same clothing. Weigh patient at the volume and fluid retention. evidence by ease of
crackles and lung sound and
same time each day breathing, clear
shortness of reduction of edema
breath lung sound and
3. Reposition the patient to an 3. Positioning the patient to an reduction of edema
upright, sitting position if tolerated. upright position will help
straighten the airway and
improve breathing.
4. Check with doctors for the need 4. Fluid restriction may be
for fluid restriction. necessary to prevent fluid
excess.
5. Administer diuretics as
5. Diuretics are effective in
prescribed.
excreting excess fluid through
the urine.
6. Refer to chest physiotherapy as
needed. 6. Chest physiotherapists can
help control fluid build-up in
the lungs through breathing
techniques.

NURSING CARE PLAN (IMPAIRED GAS EXCHANGE)

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Impaired gas After 8 hours or 1. Monitor the color of skin and 1. Peripheral cyanosis (bluish GOAL MET.
Objective: exchange related rendering my mucous membrane discoloration of the skin, ear
- pale to ventilation nursing lobes, or nail beds) may be After 8 hours or
- dyspnea perfusion intervention the evident with hypoxemia. rendering my
- abnormal RR imbalance client will Central cyanosis involving the nursing
(49) secondary to improved mucosa may indicate further intervention the
- restlessness congestive heart oxygenation and reduction of oxygen levels. client have
- bilateral crackles failure as will not show any improved
2. Encourage the patient to cough
evidence by signs of respiratory 2. Impaired small airways oxygenation and
to expectorate thick sputum.
crackles upon distress experience impaired gas will not show any
Suction as needed.
auscultation exchange primarily due to signs of respiratory
thick, tenacious mucoid distress
secretions. The patient may be
unable to cough the phlegm,
therefore deep suctioning may
be required.
3. Provide humidified oxygen as
prescribed. 3. To reduce the risk of drying
out the lungs.
4. Reposition the patient by
elevating the head of the bed and 4. To improve the delivery of
encouraging him/her to sit on an oxygen in the airways and to
upright position. Encourage pursed reduce shortness of breath and
lip breathing and deep breathing risk for airway collapse.
exercises.

5. Assess the patient's vital signs

and characteristics of respirations 5. To assist in creating an
at least every 4 hours accurate diagnosis and monitor
effectiveness of medical
treatment.
6. Administer medications as
prescribed. 6. Diuretics are prescribed to
reduce the alveolar congestion.
 Bronchodilators increase the
delivery of oxygen by means of
improving the dilation of small
airways.
7. Encourage small but frequent
meals 7. To avoid abdominal
distention and diaphragm
elevation which can lead to a
decrease in lung capacity.