CALMA, Mary Ann C.

BSN – IV-LEININGER

Skill: Breathe Comfortably Nursing Care Plan

Complete the nursing care plan based on the stated nursing intervention on a client with acute respiratory condition. Some intervention may be added like,
administering mucolytic but remain focus on the skill from the course outline. Point: 3 points per column. First table refers to effective NCP and 2 nd table for
ineffective NCP r/t to the acute respiration condition. Remember the case #2 from the discussion where the case description is “The patient was a 66-year-old
man who was admitted to an ICU for acute respiratory failure”. Add some modification in intervention as the given one is only the title

Nursing Care Plan 1

Assessment Nursing diagnosis Plan Intervention Evaluation

Actual At the end of Goal met – good sign /

symptoms
Cues ⮚ Impaired gas The client will ⮚ Chest
exchange physiotherapy
Subjective ⮚ Participate in
related to techniques (20 – 40
treatment regimen Objective
⮚ Dyspnea increased minutes) to
such as effective
alveolar- promotes optimal ⮚ Regular pulse
⮚ Hypoxia capillary
coughing within
chest expansion rate of the client
level of ability
⮚ Severe abdominal permeability, and drainage of
⮚ Decreased
pain interstitial ⮚ Expectorate secretions
edema, and respiratory rate
thickened mucus
⮚ Monitor the
decreased lung secretions ⮚ Can be able to
oxygen saturation
Objective compliance. have effective
⮚ Establish a (O2 Sat)
⮚ Ineffective coughing within
⮚ Thick mucus normal/effective
⮚ Maintain adequate level of ability
secretions breathing respiratory pattern
I/O for
pattern
⮚ Productive cough mobilization of
⮚ Ineffective secretions
⮚ Moderate airway
pneumothorax (20%) ⮚ Reinforce need for
clearance
on the right side adequate rest to
decrease dyspnea
⮚ Increased respiratory and improve
rate (28 to 30bpm) Risk
quality of life
⮚ Irregular pulse rate ⮚ Risk for
⮚ Encourage position
aspiration
 (110 bpm) of comfort.
Reposition client
⮚ Restlessness State below the
frequently if
background knowledge
⮚ I/O: 200 cc from 7:30 immobility is a
AM to 2:30 PM factor

⮚ Take a steaming
hot shower or hold
your head over a
steaming pot of
water to help thin
mucus and make it
easier to expel

Collaboration:

 Administer
mucolytic as
prescribed by the
physician

Goal un met - poor s/s

Subjective cues

⮚ “Masakit ang
dibdib ko” as
stated by the
client

⮚ Dyspnea

⮚ hypoxia

Objectives cues

⮚ The thickened
mucus secretions
cannot
expectorate all
properly
 ⮚ Productive cough
due to remaining
mucus

⮚ Decrease oxygen
saturation (90%)

Nursing Care Plan 2

Assessment Nursing diagnosis Plan Nursing Intervention Evaluation

Goal un met Actual
⮚ Impaired gas
Subjective cues
⮚ “Masakit ang
dibdib ko at
parang gasgas na
ang lalalamunan
ko” as stated by
the client
⮚ Ineffective airway
⮚ Dyspnea (feeling
of breathlessness)
⮚ hypoxia
Risk
Objectives cues
 Risk for activity
⮚ The thickened
mucus secretions  Risk for impaired
cannot
expectorate all
properly
⮚ Productive cough
due to remaining
mucus
At the end of ⮚ Surgical Insertion Goal met
of tracheostomy
The client will
exchange related ⮚ Tracheostomy
⮚ Participate in Subjective cues
to increased care
treatment
alveolar-capillary ⮚ Cannot be able to
regimen such as
permeability, experience Dyspnea
use of oxygen
interstitial edema,
and decreased
within level of ⮚ Cannot be able to
ability experience Hypoxia
lung compliance.
⮚ Maintain airway ⮚ Participated in
patency treatment regimen
clearance related
such as use of oxygen
to retained ⮚ Reduce mucus
secretions within level of ability
secretions
⮚ Maintained airway
patency
intolerance Objective cues
⮚ Oxygen saturation of
integrity 97%
⮚ Mucus secretions are
not thickened but
steamed so that it can
expectorate through
the tracheostomy
⮚ Decrease oxygen tube
saturation (90%)
⮚ Not experiencing deep
⮚ Left lower lobe coughing
collapse due to
⮚ Respiratory rate are
mucus plugging
normal
(as seen on Chest
X-Ray) ⮚ Pulse rate becomes
regular
⮚ Small left sided
pleural effusion
(as seen on Chest
X-Ray)