Nursing

Cues Inference Plan of Care Intervention Rationale Evaluation

Diagnosis

Subjective: Ineffective Mucus production Within 30 minutes 1. Assist the patient 1. To promote After 30
airway clearance of nursing into high-fowler’s maximal lung minutes of
Objective: related to intervention, the position expansion. nursing
 Inability to blockage of Prolonged bed rest patient will be intervention,
expectorate respiratory tracts able to 2. Check the 2. To assess the goal was fully
phlegm by as evidenced by demonstrate patient’s skin color. degree of O2 met as
coughing presence of Retained mucus improved deprivation. manifested by:
 Presence of crackles and secretion (presence breathing as 3. Suction the
lung snoring. of crackles) manifested by: patient’s mouth 3. To a.) Decreased
crackles and nose as mechanically crackles
 Snoring a.) decrease of needed. remove the
Ineffective cough crackles mucus present in b.) decreased
the upper amount of
b.) decrease respiratory tract. mucus in the
Pooling of mucus amount of mucus 4. Give mucolytic respiratory
in the respiratory in the respiratory agent as ordered. 5. To loosen up tract
tract tract (observed mucus at the
through 5. Nebulize the respiratory tract.
suctioning) patient as ordered.
Snoring 6. To promote
6. Administer O2 bronchodilation.
therapy as ordered.
6. To achieve O2
demand by the
body.
 Nursing
Cues Inference Plan of Care Intervention Rationale Evaluation
Diagnosis

Subjective: Disturbed sleep Interruptions of Within 8 hours of 1. Assess for 1. To lessen the After 8 hours
pattern related to sleep for medical/ nursing factors that factors that of continuous
Objective: presence of nursing intervention, the contribute to the contributes to nursing
 Lack of environmental intervention patient will attain patient’s lack of disruption of intervention,
energy factors as optimal time of sleep. Change the patient’s sleep. the goal was
 Difficulty evidenced by sleep as modifiable factors. partially met
staying lack of energy Exposure to light manifested by: 2. To eliminate as manifested
asleep and difficulty 2. Group the unnecessary by:
staying asleep. a.) increase in interventions that waking of the
Exposure to noise number of hours necessitate waking patient. a.) increased
made by machines of uninterrupted of the patient and in number of
sleep perform it at the 3. To promote hours of
same time if it optimum number uninterrupted
Lack of sleep b.) increase sense permits. of hours of sleep sleep.
of well being of the patient.
3. Render nursing b.) sense of
interventions 4. To make the well being
without waking the patient relaxed, still at low
patient whenever thus making level
possible. them easier to
get to sleep.
4. Apply measures
that will make the 5. To eliminate
patient comfortable the need of the
(giving a bath, patient to go to
changing linens the bathroom.
etc.)

5. Apply
appropriate
alternative toileting
method (catheter
for urination and
diapers for
defecation).
 Nursing
Cues Inference Plan of Care Intervention Rationale Evaluation
Diagnosis

Subjective: Self care deficit Cerebrovascular Within 3 hours of 1. Administer After 3 hours
related to disease nursing feeding via NGT of nursing
Objective: neuromuscular intervention, the tube as ordered. intervention,
 At impairment as patient will be the goal was
complete evidenced by Neuromuscular able to attain self 2. Place catheter completely
bed rest weakness. weakness care needs for urination and met as
 Slow dependently as diapers for manifested by:
movements manifested by: defecation.
 Observed Inability to a.) appropriate
weakness perform self care a.) appropriate 3. Render oral care alternative
alternative feeding to the patient. feeding
method method
4. Render bed bath
b.) appropriate to the patient. b.) appropriate
alternative alternative
toileting method 5. Change the toileting
clothing of the method
c.) improved patient regularly.
hygiene and c.) improved
grooming hygiene and
grooming