SYSTEMS PLUS COLLEGE FOUNDATION

Angeles City
COLLEGE OF NURSING

NURSING CARE PLAN

Name: Chona Date of Admission:
Age: 6 y/o Chief Complaint: Coughs and Colds with 38.6 degree fever
Sex: F Admitting Diagnosis:

Assessment Nursing Diagnosis Short-term and Long- Nursing Interventions Rationale Expected outcome
term Objectives

Subjective:
> Cough and colds 4 days
prior to admission.
Objective:
> T: 38.6 degree celsius
> Seizure Precaution (no
seizure occurance the entire
shift)
Ineffective Airway
Clearance may be related to
excessive mucus as
evidenced by ineffective
cough
Short-term:
> After 8 hours of nursing
interventions, patient will
be able to cough up
secretions, perform
coughing and deep-
breathing exercises.
Long-term:
> After 48 hours of nursing
interventions, the patient
will be able to decrease
secretions and maintain
performing coughing and
deep-breathing exercises.
1. Assess respiratory status
for rate, depth, ease, use of
accessory muscles, and
work of breathing.
2. Auscultate the lung
fields for the presence of
wheezes, crackles (rales),
rhonchi, or decreased
breath sounds.
3. Administer oxygen as
ordered. Monitor oxygen
saturation by pulse
oximetry, and notify the
physician of readings <90%
or as prescribed by the
physician.
4. Monitor patient for
cough and production
of sputum, noting
amount, color,
character, and patient’s
ability to expectorate
secretions, and the
1. Changes may vary from > After 8 hours of nursing
minimal to extreme caused interventions, patient was
by bronchial swelling, able to cough up secretions,
increased mucus secretions perform coughing and
caused by oversecretion of deep-breathing exercises.
goblet cells and
tracheobronchial infection, > After 48 hours of nursing
narrowing of air interventions, the patient
passageways, and presence was able to decrease
of other disease states that secretions and maintain
complicates the current performing coughing and
condition. deep-breathing exercises.
2. Wheezing is caused by
squeezing of air past the
narrowed airways during
expiration which is caused
by bronchospasms, edema,
and secretions obstructing
the airways.Crackles or
rales, result from
consolidation of leukocytes
and fibrin in the lung
causing an infection or by
fluid accumulation in the
ability to cough. lungs.
5. Position patient in
Decreased breath sounds
high Fowler’s or semi- may indicate alveolar
Fowler’s position, if collapse with little to no air
possible. exchange in the lung area
6. Administer being auscultated and
bronchodilators as usually results in poor
ventilation.
ordered 3. Providing supplemental
7. Encourage fluids, up oxygen benefits the
to 3-4 L/day unless patient.High-level oxygen
contraindicated. can cause severe damage to
tissues, oxygen toxicity,
8. Encourage deep
increases in A-a gradients,
breathing exercises and microatelectasis, and
coughing exercises ARDS.
every 2 hours.
9. Instruct patient on Oximetry readings of 90
correlate with PaO2 of 60
deep-breathing
mmHg and levels below 60
exercises and use of mmHg do not allow for
incentive spirometry. adequate perfusion to
10. Instruct patient to tissues and vital organs.
avoid excessively hot or 4. Mucus color from
cold fluids or yellow to green may
environmental indicate the presence of
temperature extremes. infection. Tenacious,
11. Instruct thick secretions require
patient/family to avoid more effort and energy
crowds and persons to expectorate through
with upper respiratory coughing, and may
infections when actually create an
possible. obstruction stasis that
12. Instruct leads to infection and
patient/family in the use respiratory changes.
of inhalers, nebulizers, 5. To promote maximal
lung expansion.
and medications. 6. Promotes relaxation
of bronchial smooth
muscles to decrease
spasms, dilates airways
to improve ventilation,
and maximizes air
exchange.
7. Provides hydration
and helps to thin
secretions for easier
mobilization and
removal.
8. Assists in lung
expansion, as well as
dislodgement of
secretions for easier
expectoration.
9. Promotes full lung
expansion and
decreases anxiety.
10. May predispose
patient to coughing
spells, creating dyspnea,
and bronchospasms.
11. Prevents possible
transmission of
infection to the patient
who already is
immunocompromised.
12. To provide
supporting knowledge,
and promotes the
correct administration
of medication for
optimal effect.