NURSING CARE PLAN

Patient’s Name: Cruz, Joaquin Age: 4 years old Sex: Male

Diagnosis: Pneumonia Weight: 15.2 kg Date:
Nursing Ineffective Airway Clearance Rank 1st
Diagnosis: :

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ASSESSMENT NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS EVALUATION CRITERIA
 Objective Ineffective Airway Long term: After 3days of Independent After 8 hours of intervention
- V/S taken as Clearance as evidenced by nursing intervention the 1. Monitor vital signs the patient was:
follows decreased air entry over patient will:
T- 40°C right lower lobe with 2. Assess the rate, 1. Manifested a
PR- 130 bpm crackles and increased 1. Be free of rhythm, and depth of decrease in viscosity
RR- 40 cpm vocal fremitus over the right complications respiration, chest and tenaciousness
BP- 100/70 mmHg base. caused by movement, and use of secretions
pneumonia of accessory
-awake and alert muscles. 2. Demonstrated
Short term: After 8 hours of behaviors to monitor
-moderate distress intervention the patient is 3. Auscultate lung and promote a
able to: fields, noting areas patent airway.
-erythematous of decreased or
mucosa with 2. Show decrease in absent airflow and
yellowish discharge viscosity and adventitious breath
tenaciousness of sounds: crackles,
-lips and mucous secretions wheezes.
membranes are dry
3. Demonstrate 4. Elevate head of bed,
-several small behaviors to monitor change position
anterior cervical and promote a frequently.
lymph nodes patent airway.

Dependent

1. Administer O2
inhalation as
ordered

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NURSING CARE PLAN