NURSING CARE PLAN (1)

Assessment Planning Intervention Expected

Outcome
S>Ø Within 4 INDEPENDENT: After 4 hours of
hours of 1.) Place patient into high fowler’s position nursing
O nursing R > maximize lung expansion and decrease intervention, the
> w/ productive cough of whitish in intervention, respiratory effort patient manage
color, non-mucoid the patient to achieve
> use of accessory muscle noted will manage 2.) Advise mother to do back tapping patent airway as
> tachypneic = to maintain a R > helps to manually loosen or dislodge evidenced by:
> tachycardic = patent secretions
> pale and weak in appearance airway. a. respiratory
> restlessness 3.) Assess airway patency rate is within
> irritable R > helps to check for any obstruction or normal range
> crackles on ® upper lung upon accumulation of fluids and maintain adequate
auscultation airway patency b. mucus
section is
Nsg Dx 4.) Auscultate lung fields, noting areas of decrease
Ineffective airway clearance R/T decrease or absence of airflow and adventitious
pulmonary disease as manifested breath sounds c. coughing is
by presence of mucus secretions. R > To identify areas of consolidation and minimize
determine possible bronchospasm or obstruction
SE:
5.) Advise to increase fluid intake
R > keeps mucus secretions moist and easier to
expel

6.) Maintain a relaxed, calm and non-stimulating

environment
R > Establish optimal rest/ sleep pattern.
COLLABORATIVE:
1.) Suction as order by the physician
R > Help the body rid the lungs of mucous thus
allowing easier breathing and agility.

2.) Administer the following medications as order:

a. Bronchodilator
R> Increases lumen size of the
tracheobronchial tree, thus decreasing resistance
to airflow and improving oxygen delivery.

b. Oxygen therapy
R> increase oxygen saturation in tissues
where the saturation levels are too low due to
illness or injury.

c. Antibiotics
R> to treat underlying cause of the condition
NURSING CARE PLAN (2)

Assessment Planning Intervention Expected

Outcome
S>Ø Within 4 INDEPENDENT: After 4 hours of
hours of 1.) Monitor v/s especially body temperature nursing
O nursing R> recognizing the increase in temperature can intervention, the
> elevated body temperature = intervention, help determine if there is abnormalities in the patient’s
> weak in appearance the patient’s patient. temperature will
> warm to touch temperature be normalize as
> tachycardic = will be 2.) Advise SO to do TSB evidence by
> flushy face normalize or R> helps lower body temperature decrease of
> irritable turn to a temperature
more 3.) Assess patient’s neurologic response from °C to °C
manageable R> helps note level of consciousness, reaction to
Nsg Dx manner stimuli, pupil reaction, presence of posturing or
Hyperthermia R/T disease process seizures that can affect the patient

4.) Provide proper ventilation

SE: R> Patients need enough oxygen supply that help
to normalize body temperature.

5.) Advise to loosen clothing

R> Heat should be release especially I groin and
axillae area.

6.) Maintain bed rest

R> reduce metabolic demands or oxygen
consumption

COLLABORATIVE:
1.) Administer the following as order:
 a. Oxygen therapy
R> helps offset increase oxygen demands
and consumption

b. Antipyretic drug
R> elimination of fever will interfere with its
enhancement of immune response

c. Antibiotic drugs
R> to treat underlying cause of the condition
NURSING CARE PLAN (3)

Assessment Planning Intervention Expected

Outcome
S>Ø Within 4 INDEPENDENT: After 4 hours of
hours of 1.) Assess respiratory rate, depth and ease. nursing
O nursing R> Manifestations of respiratory distress as intervention, the
> weak in appearance intervention, dependent on indicative of the degree of lung patient will be
> irritable The patient involvement and underlying general status. able to improve
> restlessness will improve ventilation and
> lethargic ventilation 2.) Monitor body temperature oxygenation as
> tachycardic = and R> High fever greatly increases metabolic evidence by:
> tachypneic = adequate demands and oxygen consumption and alter
oxygenation cellular oxygenation a. decrease of
of tissues by RR from
Nsg Dx arterial blood 3.) Monitor for skin color, mucous membranes,
Impaired Gas exchange R/T gases within nailbeds, and noting presence of peripheral or b. decrease of
presence of secretions affecting patient’s central cyanosis CR from
oxygen across alveolar membrane normal limits R> Cyanosis of nailbeds may indicate
vasoconstriction. However, cyanosis of mucous
membranes and around the mouth is indicative of
SE: systemic hypoxemia

4.) Assess patient’s neurologic response

R> helps note level of consciousness, reaction to
stimuli, pupil reaction, presence of posturing or
seizures that can affect the patient

5.) Assess heart rate and rhythm

R> may represent a response to hypoxemia

6.) Elevate head of the bed and change position

frequently
R> promotes optimal lung expansion and
expectorations or clearing of secretions

7.) Encourage adequate rest and limit activities

R> promote calm and restful environment

COLLABORATIVE:
1.) Administer medications as order.
> corticosteroids
> antibiotics
> bronchodilators
> expectorant

2.) Monitor ABG’s and pulse oximetry

R> follows progress of disease process and
facilitates alterations in pulmonary therapy