Name of Student: Princess F. Sugaton Sec. & Group No: BSN3F Gr.

NURSING CARE PLAN

ASSESSMEN NURSING RATIONALE DESIRED NURSING RATIONALE EVALUATION
T DIAGNOSIS pathophysiology/ OUTCOME INTERVENTIO
Schematic Diagram N
Subjective: ineffective Short-Term Independent NURSING After 4 days of
48 y.o. Chain smoker ASSESSMENT
“Nabudlayan ko breathing male; for 25 years Goal: series in
mag ginhawa pattern History
Bronchial of can consume After 8 hrs. Of nursing care
10 cigarrete
kag wala ga related to asthma
bronchial per day nursing the client is
Predosposing
untat akon retained asthma
factor
Precipitating
factor
interventions: able to exhibit:
ubo” as secretions • the client • The patient
•Establish rapport
verbalized by and will •To get clients was able to
between client
the patient. ineffective demonstrate trust and improved
Inflammation of the and nurse
Objective: inspiration cough cooperation airway
lungs
•Use of and effectively and
•Assess clearance as
accessory expiration expectorate • To identify the
muscle. occurring with secretions. patient’s evidenced by
signs and
•Dyspnea chronic condition symptoms and
being able to
•Productive airflow Shortness in breathing medical needs of expectorate
cough constraints as •Observe the patient. phlegm
•V/S taken as evidence by nonverbal cues effectively and
follows: difficulty of •To reinforce the client
T: 37.8 breathing Persistent and the spoken word verbalized
P: 90 BPM productive coughing and help ease of
R: 26 CPM Definition: understand how breathing.
Bp: 140/80 Abnormal a patient really GOAL MET
O2 Sat – 94% breathing Blockages reduce blood feels.
Chest X-ray; pattern (e.g., flow
pulmonary •Demonstrate
congestions rate, • Assess and • The patient
behaviors to • To identify the
rhythm, improve monitor the would increase
Arterial Blood
depth); signs and airway
Gas: decreased airway patient
PaO2, decreased altered chest symptoms and clearance in
clearance, respiration and
Ph, and ineffective breathing medical needs of response to
increased CO2 excursion; e.g., cough breathing sounds
the patient. nurse
bradypnea; effectively and (wheezing,
Pulmonary
function Test: decrease in expectorate crackles) Note the interventions.
airway secretions. inspiration and For instance,
obstruction CBC
expiratory
expiration ratio cough
with elevated pressure; thoroughly and
WBC decrease in Reference:
NANDA expectorate
inspiratory secretions.
• Administer
pressure; medications such •Bronchodilators GOAL MET
decrease in as bronchodilators decrease airway
Strengths:
minute or inhaled resistance,
Family Support ventilation; steroids improve the
decrease in asordered.3. The efficiency of
Weaknesses: vital nurse will help the respiratory
Financial capacity; patient deep movements,
Instability dyspnea; breathing and improve exercise
 increase in perform tolerance, and
anterior- controlled can reduce
posterior coughing every symptoms of
chest hour. dyspnea on
exertion
diameter;
nasal flaring;
• Help the patient • By using
orthopnea; gravity, elevating
get into a
prolonged comfortable the head of the
expiration posture by bed helps with
phase; elevating the head breathing.
pursed-lip of the bed,
breathing; encouraging them
tachypnea; to lean on the
use of overbed table, or
accessory encouraging them
to sit on the edge
muscles to
of the bed.
breathe; use Long-Term
of three- Goal: After
point 2-3 weeks of
position nursing
Source/ interventions:
Reference:
NANDA • Improve a
patient's
functional
status and • Depending on
quality of life • Allergic or • Client will be
the specific
by preserving respiratory able to identify
scenario, reduce
optimal lung precipitators and avoid
environmental
function, that may cause potential
pollutants to a
improving or aggravate the allergens or
minimum, such as
symptoms, commencement stimuli that
dust, smoking,
and of an acute would trigger
and feather
preventing episode. asthma attack
pillows.
the and be able to
recurrence of handle
• Promote or help
exacerbations. • Gives the symptoms if
with exercises for
patient some recurrence
breathing via
tools to manage comes, prompt
pursed lips.
or minimize follow up
dyspnea and checkup and to
lessen air always bring or
entrapment. have the
prescribed
• Observe medications on
• After chest
characteristics of hand in case
percussion,
cough like asthma occurs.
coughing is most
persistent or GOAL MET
effective when
hacking or moist. done in an
Assist with upright or head-
measures to down position.
improve
effectiveness of
cough effort.
Observe
characteristics of
cough like
persistent or
hacking or moist.
Assist with
measures to
improve
effectiveness o
cough effort.

Collaborative
• Dispense
medicine as • A number of
directed by the drugs can be
doctor. used to reduce
mucus and
enhance
• Offer additional breathing.
humidification, • Humidity may
such as a lessen or
nebulizer. prevent the
development of
thick mucus
plugs in the
bronchioles by
reducing the
viscosity of
secretions,
which facilitates
expectoration.