Planning 

 
Nursing Care Plan 
Assessment  Nursing Diagnosis  Planning  Intervention  Rationale  Expected Outcome 
Subjective Data:  Ineffective airway After 2 hours of Independent:    After 2 hours of proper
“Hindi ako masyadong makatulog  clearance related to proper Nursing     Nursing intervention
sa gabi dahil ubo ako ng ubo”, as bronchospasm as intervention the -Encourage the -To allow help maximize v the client was able to
verbalized by the client.  evidenced by client will able patient to deep entilation.  demonstrate behaviors
  Cough  to demonstrate coughing exercise    to improve airway
Objective Data:  behaviors to   -The some degree of clearance 
-Fatigue  improve airway -Auscultate breath bronchospasm is present
  clearance  sounds. Note with obstructions in
-Productive Cough  adventitious breath the airway. 
  sounds (wheezes,  
-Presence of crackles on both crackles, rhonchi).  -To identify the occurrence
lungs field upon auscultation    of an infectious process. 
  -Observe the sign  
-Restlessness   and symptoms of -To promote wellness. 
  infections.   
-Orthopnea     
   -Encourage -To promote better lung
Vital Signs:  the patient to expansion and improved
BP – 160/90 mmHg  adequate bed rest.  gas exchange. 
     
PR – 110 bpm  -Position the patient -Ineffective cough may
  in High-fowlers also signal
RR – 25 cpm  position.  impending respiratory failu
    re. 
T – 36.9 C     
  -Monitor the -Hydration helps decrease
O2 – 90 %  cough and the viscosity of secretions,
  sputum for color, facilitating expectoration. 
  consistency and am  
 ount.  -This techniques will
  prevent possible aspirations
-Increase fluid and prevent any untoward
intake to 3000 mL complications. 
per day within  
cardiac tolerance.   
   
  -To treat
  for possible complication
-Demonstrate chest and infection. 
physiotherapy, such
as bronchial tapping
when in cough,
proper postural
drainage. 
 
 
Dependent: 
-Administer
medication as
ordered. 
 
 
 
 

 
 
 
 
 
Assessment  Nursing Planning  Intervention  Rationale  Expected Outcome 
 Diagnosis 
Subjective Data:  Impaired gas After 2 hours of Independent:    After 2 hours of Proper
“Hindi ako masyadong makahinga”, exchange Proper Nursing -Encourage the patient deep -To promotes optimal chest Nursing Intervention the
as verbalized by the client.  related to Intervention the breathing exercise.  expansion and client was able to
  altered oxygen client will able to   drainage secretions.  demonstrate improved
Objective Data:  supply as demonstrate     ventilation and
-Dyspnea  evidenced by improved -Monitor the -Rapid, shallow breathing free from symptoms of
  dyspnea  ventilation and respirations, quality, and hypoventilation affect respiratory distress 
-Abnormal breathing pattern  free from symptoms rate, pattern depth and gas exchange by affecting  
  of respiratory breathing effort.  CO2 levels. 
-Abnormal breath sounds  distress     
      -To reveals presence of
-Hypoxemia  -Auscultate breath sounds pulmonary
  and noting for congestion/collection of
-Hypoxia  crackles, wheezing.  secretion indicating need
  for further intervention. 
   
  -For mobilization
-Maintain of secretions. 
adequate fluid intake   
  -To decrease dyspnea and
-Encourage the patient to improve quality of life. 
adequate sleep and rest.   
  -To maintain airway. 
-Elevate the head of patient  
or position the  
patient appropriately.   
   
-Monitor changes in the  
level of consciousness and -Restlessness, agitation,
mental status.  and anxiety are common
  manifestations of hypoxia. 
   
Dependent:   
-Administer medication -To loosen secretions of
as ordered.  the airways and improving
  gas exchange. 
   
-Administer supplemental -To prevents drying out
oxygen as ordered.  the airways. 
Assessment Diagnosi Planning Intervention Rationale Evaluation
s
Independent:
Subjective: Ineffective After 8 After 8 hours
breathing hours of  Assess  Manifestation of nursing
“Pakiramdam ko pattern nursing patient’s of respiratory intervention
related to
sobra akong pagod interventio respiratory distress the patient
Retained
at hirap ako sa pag n the status every include was able to
Secretions
hinga nung ilang as patient will 2 to 4 hours shortness of improved
linggo na ganito evidenced be able to as indicated breath, breathing
ang pakiramdam by improved and notify tachypnea, pattern and
ko” as verbalized Presence breathing any abnormal changes in maintain a
by the patient. of non- pattern and findings. mental status respiratory
productive maintain a and the use of rate within
Objective: cough respiratory accessory normal
rate within muscles. limits.
 Fatigue normal  Monitor vital  For baseline
 Shortness of limits. signs data.
breath  Auscultate  Decreased
 Cough breath breath sounds,
 Restlessnes sounds every crackles,
s 2 to 4 hours wheezes, and
 Disturbed as indicated. rhonchi can be
sleep due to observed and
coughing must be
reported
Vital Signs: promptly for
 BP: 164/92 immediatemen
mmHg t treatment.
 PR: 110
bpm  Instruct how  Promotes
 RR: 25cpm to splint the physiological
 Temp: chest wall ease of
36.9°C with a pillow maximal
 O2 sat: 93% for comfort inspiration.
during
drop to 90%
coughing and
on the elevation of
following head over the
excertion body as
 Height: 5ft. appropriate.  Aid in
2 inches  Provide relieving the
 Weight: 180 respiratory patient from
lbs. support. dyspnea.
Oxygen