NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective: Ineffective Breathing Within 4 hours of nursing Assess respiratory rate Frequent assessment and After 4 hours of nursing
N/A Pattern related to viral interventions, the patient will frequently monitoring provide interventions, the patient
inflammatory process be able to: objective evidence of was able to:
Objective: changes in the quality of
• Show adequate respiratory effort, enabling • Show adequate
Vital Signs: ventilation presented by prompt and effective ventilation presented by
BP - 130/72 respiratory rate within intervention. respiratory rate within
PR – 188 normal limits. normal limits
RR – 83 Auscultated breath sounds; Crackles indicate
• Display ease of breathing. noted areas with presence accumulation of secretions • Display ease of
SaO2 – 94% placed on
• clear breath sounds with of adventitious sounds. breathing.
1.5 L O2 and inability to clear
adequate oxygen • clear breath sounds
airways.
saturation >94% with adequate oxygen
• Respiratory panel
Checked for obstructions saturation as evidenced
showing presence To maintain adequate
or accumulation of by SaO2 increased to
of respiratory airway patency.
secretions. 97%
syncytial virus
(RSV)
• Fussy Position for comfort with GOAL MET
• Difficult to console to ensure optimal
open airway and room for ventilation via maximum
lung expansion and use
lung expansion
pillows or padding if
necessary to maintain
position

Initiate and administer IV To make it easier to suction

fluids as necessary or expel

Provide suction as To help clear airways. Avoid

necessary excessive or prolonged
suction that can cause
further inflammation of the
airways

Continue administering To improve oxygenation

supplemental oxygen
and/or humidity as ordered

Administer medications
and breathing treatment to improve patient’s
such as albuterol nebulizer respiratory status
trial, and IV bolus