NURSING CARE PLAN
NAME: Mr. M
cc: persistent cough
Cues
Subjective:
The patient reported
persistent cough, chills and
rigors, shortness of breath,
and sharp chest pain with
cough and deep inspiration
for three days. He also
stated that he experienced
nausea and vomiting.
Objective:
 Productive cough of
green sputum
 In moderate respiratory
distress
 Mild expiratory
wheezes throughout all
lung fields
 Scattered rhonchi,
crackles, and
egophony at the right
lower and mid-lung
fields.
Vital signs as follows:
 T = 40◦C ; fever
 RR = 30 bpm
 PR = 120 bpm ;
tachycardic
 BP = 110/65 mmHg
 O2 Sat= 96%
AGE: 62 years old SEX: Male
ADMITTING/WORKING DIAGNOSIS: Pnuemonia
Nursing Outcome Criteria Intervention Rationale Evaluation Discharge Planning
Diagnosis
Ineffective Short Term INDEPENDENT: Short Term M- Instruct the patient
Airway After 8 hours of -Assess the -Tachypnea, shallow After 8 hours of to take medications on
Clearance nursing respiratory rate, respirations and asymmetric nursing intervention: time as prescribed by
related to interventions: depth, rhythm, and chest movement are frequently the physician and give
increased chest movement. present because of discomfort 1. MET. The patient information about
sputum 1. The patient will of moving chest wall and/or fluid was able to show purposes and side-
production as show in lung due to a compensatory temperature within effects of the
evidenced by temperature response to airway obstruction. normal range as medications and
within normal evidenced by 36.9C. treatments.
range. -Coughing is the most effective
-Assess cough way to remove secretions. 2. MET. The patient E- Provide and
2. The patient will effectiveness and Pneumonia may cause thick was able to encourage an
demonstrate productivity and tenacious secretions to demonstrate atmosphere of realistic
behaviors to patients. behaviors to achieve hope for the patient.
achieve airway airway clearance as Environment free from
clearance. -Oxygen saturation is a term evidenced by proper irritants is also needed
-Monitor oxygen referring to the fraction of breathing exercises. for patient’s optimal
saturation. oxygen-saturated hemoglobin recovery.
3. The patient will
relative to the total hemoglobin 3. MET. The patient
maintain
in the blood. Normal oxygen was able to maintain T- Encourage the
patent airway
saturation levels are considered patent airway with patient to perform self-
with breath
95-100%. breath sounds soothing relaxation
sounds
clearing, as techniques.
clearing, as
-Doing so would lower the evidenced by clear
evidenced by -Elevate head of bed,
diaphragm and promote chest breath sounds upon H- Encourage the
keeping a change position
expansion, aeration of lung auscultation patient to comply to his
patent airway. frequently.
segments, mobilization and medications and
expectoration of secretions. contact health provider
for further questions.
-Deep breathing exercises
-Teach and assist facilitates maximum expansion O- Instruct the patient to
patient with proper of the lungs and smaller comply with follow-up
deep-breathing airways, and improves the check-ups.
exercises. productivity of cough.
D- Instruct the patient to
avoid eating sugary
-Fluids, especially warm liquids, foods, caffeine, food
-Increase adequate aid in mobilization and with preservatives and
hydration by forcing expectoration of secretions. avoid alcoholic
fluids to at least 3000 Fluids help maintain hydration beverages.
mL/day unless and increases ciliary action to
contraindicated remove secretions and reduces S-   Encourage folks to
the viscosity of secretions. always be there for the
 Thinner secretions are easier to
cough out.
-This helps loosen and mobilize
-Chest physiotherapy secretions in smaller airways
after nebulization. that cannot be removed by
coughing or suctioning.
patient. Having a strong
support system can
boost one’s optimal
health.
S- Encourage the
patient to find comfort in
prayer to strengthen
coping abilities.

-Appl TSB to the -Tepid sponge

patient. bath is considered as one of the
best cooling treatments. It is
effective in relieving fever by
reducing high temperature and
also helpfulin alleviating pain or
discomfort.

DEPENDENT: -Pharmacological interventions

-Administer the are needed to alleviate
following medications discomfort and effective in
as ordered by the managing pain when non-
physician: pharmacological methods are
perceived to be ineffective.

-To reduce the fever if non-

-Acetaminophen pharmacological interventions
was not effective.
-Analgesics -Analgesics are given to
improve cough effort by
reducing discomfort, but should
be used cautiously because
they can decrease cough effort
and depress respirations.

-Mucolytics increase or liquefy

-Mucolytics respiratory secretions.

-Expectorants increase
-Expectorants productive cough to clear the
airways. They liquefy lower
respiratory tract secretions by
reducing its viscosity.

-Bronchodilators are
-Bronchodilators medications used to facilitate
 respiration by dilating the
airways.

-Oxygen therapy For severe cases that the

patient can’t breathe on his own.

REFERENCES:

https://nurseslabs.com/pneumonia-nursing-care-plans/