PHINMA UNIVERSITY OF PANGASINAN

COLLEGE OF ALLIED HEALTH SCIENCES - DEPARTMENT OF NURSING

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE PLANNING RATIONALE INTERVENTION EVALUATION

Impaired Adventitious breath  Client will Spontaneous INDEPENDENT:  Client can
Spontaneous sounds such as maintain breathing during maintain
Ventilation RT wheezes and crackles spontaneous ventilator support  Maintain the client’s airway. spontaneous
Respiratory are an indication of gas exchange may prevent Use the oral or nasal airway gas exchange
muscle fatigue respiratory resulting in increase in sedation as needed. resulting in
AEB Adventitious difficulties. reduced beyond a level of reduced
breath sounds dyspnea, comfort to adapt the  Maintain client in a High- dyspnea,
normal oxygen patient to Fowler’s position as normal
saturation, mechanical tolerated. Frequently check oxygen
normal arterial ventilation which the position. saturation,
blood gases decreases duration normal arterial
(ABGs) within of mechanical  Encourage deep breathing blood gases
client ventilator support, and coughing exercises. (ABGs)
parameters. length of stay in the within client
intensive care unit,  Use nasotracheal suction as parameters.
and overall costs of needed if coughing and deep
care giving. breathing are not useful.  Client can
demonstrate
 Client will  Notify the respiratory an absence of
demonstrate an therapist to bring a complications
absence of mechanical ventilator. from the
complications mechanical
from the  If possible, before intubation, ventilation.
mechanical explain to the client the steps
ventilation. and purpose of the procedure
and the temporary inability to
speak (due to the ET tube
passing through the vocal

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 cords).

COLLABORATIVE:

 Administer sedation as
ordered.

 Place the client in a supine

position, hyperextending the
neck unless contraindicated
and aligning the client’s
oropharynx, posterior
oropharynx, and trachea.

 Apply cricoid pressure as

directed by the physician.

 Provide oxygenation and

ventilation using an Ambu
bag and mask as needed
before and after each
intubation attempt. If
intubation is difficult, the
physician will stop
periodically so that
oxygenation is maintained
with artificial ventilation by
the Ambu bag and mask.

 Assist with the verification of

correct ET tube placemen.
Use a carbon dioxide detector
as indicated.

 Continue with manual Ambu

bag ventilation until the ET
tube is stabilized. Assist in

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 securing the ET tube once
tube placement is confirmed.

 Document the ET tube

position, noting the
centimeter reference marking
on the ET tube.

 Insert an oral airway and/or

bite block for the orally
intubated client.

 Use bilateral soft wrist

restraints as needed,
explaining the purpose of
their use.

 Institute mechanical
ventilation with prescribed
settings.

 Institute aseptic suctioning of

the airway.

 Anticipate the need for

nasogastric and/or oral
gastric suction.

 Administer muscle-
paralyzing agents, sedatives,
and opioid analgesics as
ordered.

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ASSESSMENT DIAGNOSIS INFERENCE PLANNING RATIONALE INTERVENTION EVALUATION
 Examine the
cuff volume by
checking
whether the
client can talk
or make sounds
around the tube
or whether
exhaled
volumes are
significantly
less than
volumes
delivered. To
correct, slowly
reinflate the
cuff with air
until no leak is
detected.
Notify the
respiratory
therapist to
check cuff
pressure.

 Respond to
alarms, noting
that high-
pressure alarms
may be of
client
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 resistance or
the client’s
need for
suctioning. A
low-pressure
alarm may be a
ventilator
disconnection.
If the source of
the alarm
cannot be
located,
ventilate the
client with an
Ambu bag until
assistance
arrives.

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