NURSING PROCESS CARE PLAN
Data Cluster Nsg. Diagnosis
Assessment (Objective data):
Assessment (Subjective data):
Assessment (Objective
Assessment (Subjective data):
Assessment (Objective
data):patient called he
suffering from Fatigue and
non producting Cough and he
NDR 208 (NURSING PROCESS CARE PLAN- 2021-2022)
S.T Goals and Objectives
ineffective AIRWAY Maintain airway
CLEARANCE
patency while
admission
Impired gas exchang Target time from one week
due Dyspnea to three week
Target to treatment the all
respiratory problem and
difficult of breathing
Impired gas exchang Target time from one week
due Dyspnea to three week
Target to treatment the all
respiratory problem and
Intervention Rationale Evaluation
1. Elevate head of bed/change  to take advantage of gravity Goal met as evidenced by
position every 2 hours and decreasing pressure on the
prn maintain airway patency
diaphragm and enhancing
drainage of/ventilation to
while admission
2. Encourage deep-breathing different lung segments.
and coughing exercises; splint  to maximize effort of mobilize
chest/incision secretions
3. Support reduction/cessation
of smoking  to improve lung function.
1- ------------ 1--------------
2- ------------- 2---------------
3- ------------- 3-------------
1- Reassure the patient’s 1- Essential monitoring of
family while the patient respiratory and ventilator
is on ventilator. effectiveness
2- Monitor vital signs,
especially respiratory
status, at least every 2 Monitors effectiveness of
hours
3- Review the patient’s therapy
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suffer from respiratory difficult of breathing resources and support 3 Initiates timely home
systems for for
distress management of care planning
ventilator at home
Assessment (Subjective data): . Ensure 4-coordination of
4- • Collaborate with
data):Tachypnea respiratory therapists as care
needed. o
Hypoxia
BMI: obese
use of accessory muscles for
respiration,
Bronchial breath sounds

Student Name: __________________________

NDR 208 (NURSING PROCESS CARE PLAN- 2021-2022) Page 2