GUINTO, Manuel Archie D.

BSN 143 / Grp 170

Nursing Care Plan

CUES NURSING INFERENCE GOAL INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Subjective: Ineffective Chronic GOAL:
“Nahihirapan airway obstructive
ako clearance pulmonary After nursing • After nursing
huminga” as related to disease interventions, intervention
verbalized by increased (COPD) is a the client will s, the client
the production of disease demonstrate was able to
patient. secretions. characterized behaviors to demonstrate
Objective: by airflow improve behaviors to
• Use of limitation that airway improve
accessory is not fully clearance. airway
muscle. reversible. Air e.g. cough clearance.
• Dyspnea flow limitation effectively e.g. cough
• Productive is usually and effectively
cough progressive expectorate and
• V/S taken as and secretions. expectorate
follows: associated secretions.
T: 36.7 with an Objectives: Independent: • Elevation of
P: 57 inflammatory • Positioning the • Assist patient the
R: 25 response in client. to assume head of the
Bp: 100/80 the lungs position of bed
stimulated by comfort, e.g., facilitates
irritants. elevate head respiratory
Common of bed, function
cause of encourage by use of
COPD is patient to lean gravity.
cigarette on overbed
smoking, air table or sit on
pollution, the edge of
allergens and • Keeping the the bed. • Precipitator
infections that client free of • Keep s of
may also act pollution. environmental allergic type
as irritants. pollution to a or
minimum, respiratory
e.g., dust, reactions that
smoke and can
feather trigger or
pillows, exacerbate
according to onset
individual of acute
situation episode.
• Encouraging • Provides
the • Encourage or patient
importance assist with with some
of pursed lip pursed lip means
breathing breathing to cope or
exercises. exercises. control
dyspnea and
reduce air
trapping.
• Observation • Coughing is
of the client. • Observe most
characteristics effective in an
of cough like upright
persistent or position or
hacking or head down
moist. Assist position
with measures after chest
to improve percussion.
effectiveness
of cough effort
• Providing the
client’s
Dependent: • A variety of
needed • Administer medications
medication. medication as may
 prescribed by be used to
the physician. decrease
mucus
and to
improve
respiration.
• Providing the • Humidity
client with • Provide helps
the right supplemental reduce
humidifier. humidification viscosity of
like nebulizer. secretions,
facilitating
expectoration,
and
may reduce
or
prevent
formation
of thick
mucus
plugs in
bronchioles