St.

Anthony’s College
San Jose, Antique
Nursing Department
NAME: S.L
AGE: 75
Dr.: Baterna
CC: Cough NURSING CARE PLAN
CUES NURSING RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE: na budlayan Ineffective airway • Patient's sputum GENERAL: INDEPENDENT:
ako mag ginhawa kg clearance related will be clear, white, • Maintain airway • Monitor respirations • To maintain • After 8 hours of nursing
nahapo ako " as verbalize to increased and thinner in patency and breath sounds, adequate, patent interventions, the patient was
by the patient" secretions. consistency within noting rate and sounds airway. able to display stable weight,
8hours. Specific: (e.g., tachypnea, stridor, vital signs, within patients
• Patient's lungs • Expectorate/clear crackles, or wheezes) normal range and nearly
sounds will be at secration readily • Monitor vital signs, • To assess changes, absence of edema.
baseline within • Verbalize noting changes in blood note complications:
8hours. understanding of pressure and heart rate.
• Patient's respiratory causes and therapeutic • Evaluate changes in
rate will be between management regimen. sleep pattern, noting
16 and 20 within • Demonstrate insomnia or daytime
8hours. behaviors to improve somnolence, which may
• Patient's will be or to maintain clear be evidence of nighttime
OBJECTIVE: Difficulty in able to clear airway airway. airway incompetence or
breathing secretions by sleep apnea. ( LRefer to
coughing in 8hours. NDs Insomnia, Sleep
VS to be follow: Deprivation.)

BP: 120/80
Temp: 36.4
RR: 20
PR: 53
O2: 96