MYLIN Y.

GUERZO
BSN-1B

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

SUBJECTIVE DATA: Ineffective Airway After 8 hour shift of -auscultate breath sounds After 8 hour shift of
Clearance related to rendering effective nursing -monitor respiratory rate rendering effective nursing
“Nahihirapan ako increased mucous intervention, the patient -advise patient to increase intervention, goal met as
huminga” as verbalized by production secondary to will manifest effective fluid intake to more than 8 manifested by:
the patient. Pneumonia airway clearance as glasses per day - absence of pale skin,
manifested by: -position in semi-fowler/ lips, and mucous
OBJECTIVE DATA: - absence of pale skin, lips, high fowlers safely and membrane
and mucous membrane comfortably - (-)restless
-pale skin, lips, and - (-)restless -do back tapping every - patient should
mucous membrane - patient should after nebulization expectorate greenish color
-restless expectorate greenish color -demonstrate to patient sputum, approximately 2-3
-with productive cough, sputum, approximately 2-3 and assist with coughing cc in amount
patient is able to cc in amount and proper deep breathing - absence abnormal breath
expectorate greenish color - absence of abnormal -encourage patient sound upon auscultation
sputum, approximately 1-2 breath sound upon ambulate if possible over lung field
cc in amount auscultation over lung
-with abnormal breath field -Nebulization as vital signs
sound upon auscultation -RR is within the normal prescribed BP: 120/80 mmHg
over lung field range of 12-20 cpm -Give expectorants as RR:20 cpm
prescribed PR: 69 bpm
-vital signs -Give antibiotics as Temp: 37.5o C
BP: 120/80 mmHg prescribed
RR:28 cpm(fast and
shallow breathing)
PR: 69 bpm
Temp: 37.5o C