Nursing

Care
plan
 CUES PROBLEM SCIENTIFIC DESIRED INTERVENTION/ EVALUATION
REASON OUTCOME RATIONALE
STANDARD CRITERIA
Ineffective Ineffective airway Short term goal: Independent:
airway clearance occurs • Auscultate breath
clearance when an artificial After 6 hours of sounds. Note The patient Outcomes
related to airway is used Nursing adventitious breath will be able partially met,
Objective: increase because normal Intervention, the sounds like wheezes, to breathes the patient
• Nasal production of mucociliary transport Patient breathes crackles and rhonchi. without nasal was able to
Flaring mucus mechanisms are without using nasal flaring with demonstrate
secretion bypassed and flaring. Rationale: RR of 35bpm behavior to
• Abnormal impaired. • Some degree of to 28bpm improved
breath Long term goal: bronchospasm is airway
sounds. present with clearance
(crackles) After 3 days of obstructions in airway
nursing intervention and may or may not be
 Productive the patient breathes manifested in
cough normally. adventitious breath
(transparent) sounds.

V/S taken as • Keep

follows: environmental
pollution to a minimum
RR-35 like dust, smoke and
feather pillows,
according to individual
situation.

 CUES PROBLEM SCIENTIFIC DESIRED INTERVENTION/ EVALUATION
REASON OUTCOME RATIONALE STANDARD CRITERIA

Subjective: Acute pain Ash fall dust Short term INDEPENDENT The patient will The patient
r/t localized causes goal: relief of pain was relief on
inflammation difficulty of 1. Elevate head of and pain and
and breathing to After 4hrs of the bed, change demonstrate demonstrated
persistent the person nursing position relaxed relaxed
Objective: cough. who inhale at interventionthe frequently. manner, manner,
lot of it. patient will relief resting/sleepin resting/sleepi
•Use of of pain and  Lowers
Because of diaphragm, g and ng and
accessory demonstrate
the that it will promoting chest engaging in engaging in
muscle. relaxed manner,
go through the expansion and activity activity
airway and resting/sleeping
•Productive
and engaging in expectoration of appropriately appropriately.
cough causes secretions.
inflammation activity
(transparent)
and persistent appropriately. 2.Assist patient The patient will
•Restlessness cough. with deep free from pian
breathing
•Fatigue
exercises
•V/S taken as
 Deep breathing
follows:
facilitates
RR: 35 cpm maximum
expansion of
HR:142 bpm the lungs and
TEMP: 36.6 smaller
airways.
3. Demonstrate or
help patient learn
to perform activity
like splinting chest
and effective
coughing while in
upright position.

 Coughing is a
natural self-
cleaning
mechanism.
Splinting
reduces chest
discomfort, and
an upright
position favors
deeper, more
forceful cough
effort.