ST.

ANTHONY’S COLLEGE
Nursing Department

NURSING CARE PLAN

Name of patient: __K.Y.M Attending Physician: ___Dra.J.D.R___
Age: __3 years old___ Ward/Bed #: _____________ Impression Diagnosis: ____________________________

Clustered Cues: Nursing Diagnosis Rationale Outcome Criteria Nursing Interventions Rationale Evaluation

Subjective: Ineffective airway Inability to clear secretions or After 8 hours of nursing Monitor respirations and Those are indicative bof After 8 hours of
"apat dun ka adlaw clearance related to obstructions from the intervention, the client breath sound, noting rate respiratory distress and/or nursing intervention
gaubo bata ko kag obstructed airway respiratory tract to maintain a will be able to: and adventitious breath accumulation of secretions. K.Y.M was able to
lima tana ka adlaw (excessive mucous). clear airway. sounds. expectorate/clear
na sip-on" as 1. Maintain airway secretions readily and
verbalized by the patency. Monitor child for feeding That may compromise maintain airway
mother 2. Expectorate/clear intolerance, abdominal airway. patency as evidenced
secretions readily. distention, and emotional by:
stressors. Absence of
adventitious breath
Objective: Administer medications sounds
Wt: 14 kg as indicated. To relax smooth respiratory Noiseless respirations
Ht: 96 cm musculature, reduce airway No nasal watery
T: 36.4 °C edema, and mobilize discharge
secretions.
> runny nose; clear Increase fluid intake to
watery discharge at least 2,000mL/day. Hydration can help prevent
>adventitious breath the accumulation of viscous
sound; wheezing secretions and improve
secretion clearance.