PHINMA-UNIVERSITY OF ILOILO

COLLEGE OF ALLIED HEALTH SCIENCES

Nursing Department

NURSING CARE PLAN

NURSING NURSING
ASSESSMENT PLANNING RATIONALE EVALUATION
DIAGNOSIS INTERVENTIONS

SUBJECTIVE: Ineffective Breathing SHORT TERM: INDEPENDENT: INDEPENDENT: Short term goals are met as
Pattern secondary to evidenced by:
- "Nabudlayan ako mag Pneumonia as evidenced After 4 hours of nursing 1. Monitor and document 1. To detect early signs of
ginhawa," as verbalized by coughing, dyspnea, and intervention: respiratory rate and depth at respiratory compromise. - Patient exhibited improved
by the client. verbalization of the client, least every 4 hours. breathing pattern.
- Patient will exhibit 2. Unusual breathing
“nagbudlayan ako mag improved breathing pattern. 2. Observe breathing patterns patterns may imply an - Patient demonstrated deep
ginhawa.” underlying disease process breathing exercises to establish
- Patient will demonstrate 3. Auscultate breath sounds at or dysfunction. normal respiration.
deep breathing exercises to least every 4 hours.
establish normal respiration. 3. Is to detect decreased or - Patient obtained respiratory rate
4. Place patient with proper adventitious breath sounds. within established limits.
- Patient will obtain body alignment for maximum
OBJECTIVE: respiratory rate within breathing pattern. 4. A sitting position permits
established limits. maximum lung excursion
- BP: 120/70 5. Perform coughing and deep and chest expansion. Long term goals are met as
breathing exercises. evidenced by:
- T: 36 °C 5. These techniques promote
6. Encourage frequent rest deep inspiration, which - Patient maintains an effective
- RR: 10 periods and teach the patient to breathing pattern, as evidenced by
LONG TERM: increases oxygenation and
pace activity. prevents atelectasis. relaxed breathing at normal rate
- PR: 114
After 2 days of nursing and depth and absence of dyspnea.
- SPO2: 93 intervention: 6. Extra activity can worsen
shortness of breath. - Patient maintains respiratory rate
DEPENDENT: within 12-20 breaths per minute.
- Patient will maintain an
effective breathing pattern, 1. Antibiotics as prescribed. - Patient demonstrate deep
Cough
as evidenced by relaxed DEPENDENT: breathing.
breathing at normal rate and 2. Administer oxygen as
Ronchi sounds upon
depth and absence of ordered. 1. It works by stopping
auscultation dyspnea.
Difficulty of breathing - Patient will maintain
respiratory rate within 12-20
Chest pain breaths per minute.
-Patient will demonstrate
deep breathing exercises.
the growth of
bacteria.
COLLABORATIVE: 2. To promote
oxygenation.
1. Collaborate with the
Respiratory therapist and
attending physician to address
the ineffective breathing COLLABORATIVE:
pattern.
Teaching of deep breathing
and coughing exercises, and
prescription of preferred
medication for difficulty of
breathing
 PHINMA-UNIVERSITY OF ILOILO
COLLEGE OF ALLIED HEALTH SCIENCES
Nursing Department

NURSING CARE PLAN

NURSING NURSING
ASSESSMENT PLANNING RATIONALE EVALUATION
DIAGNOSIS INTERVENTIONS

SUBJECTIVE: Ineffective Airway SHORT TERM: INDEPENDENT: INDEPENDENT: Short term goals are met as
Clearance secondary to evidenced by:
"Nabudlayan ako mag pneumonia as evidence by After 8 hours of nursing 1. Assess the rate, rhythm, and 1. Tachypnea, shallow
ginhawa" as verbalized. coughing, dyspnea and interventions: depth of respiration, chest respirations and
ronchi sounds upon movement, and use of asymmetric chest
accessory muscles. movement are Respiratory rate is within normal
auscultation range.
Patient will frequently present
identify/demonstrate because of the
behaviors to achieve airway 2. Elevate the head of the bed discomfort of
clearance. and change position frequently. moving the chest Demonstrate behaviors achieving
wall and fluid in the airway clearance.
lung due to a
compensatory
OBJECTIVE: Patient will display/maintain 3. Teach and assist the patient
response to airway Maintained a patent airway with
a patent airway with breath with proper deep-breathing
obstruction. Altered breath sounds clearing as evidence
- BP: 120/70 sounds clearing; absence of exercises. Demonstrate proper
breathing patterns of absence of dyspnea
dyspnea splinting of the chest and
- T: 36 °C may occur together
effective coughing while in an
with accessory
- RR: 10 upright position. Encourage the
muscles to increase
Patient's respiratory rate patient to do so often.
chest excursion to
- PR: 114
will be in normal range facilitate effective
- SPO2: 93 breathing.

2. To lower the
4.Assist and monitor effects of Long term goal was met as
diaphragm and
Cough nebulizer treatment and other evidenced by:
promote chest
respiratory
Ronchi sounds upon expansion, aeration
of lung segments,
auscultation LONG TERM:
Difficulty of breathing After 2 days of nursing
intervention, the patient will:
Chest pain
Maintain patent airway with
breathing sounds clearing as
evidence by absence of
dyspnea.
DEPENDENT:
1. Administer medications such
as
Mucolytics, Expectorants,
Bronchodilators and Analgesics.
2. Use humidified oxygen or
humidifier at the bedside.
COLLABORATIVE:
1. Consulting with a respiratory
therapist when the patient has
deteriorating oxygen saturation
levels.
mobilization, and Maintained a patent airway with
expectoration of breathing sounds clearing as
secretions. evidence by absence of dyspnea.
3. Deep breathing
exercises facilitate
the maximum
expansion of the
lungs and smaller
airways and improve
the productivity of
cough.
-Coughing is a reflex and a
natural self-cleaning
mechanism that assists the
cilia in maintaining patent
airways. It is the most
helpful way to remove most
secretions.
-Splinting reduces chest
discomfort and an upright
position favors deeper and
more forceful cough effort
making it more effective.
4. Nebulizers humidify
the airway to thin
secretions and
facilitate liquefaction
and expectoration of
secretions.
DEPENDENT:

1. Mucolytics increase or
liquefy respiratory
secretions.

Expectorants increase
productive cough to clear
the airways by liquefying
lower respiratory tract
secretions and reducing their
viscosity.

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

Analgesics are given to

improve cough effort by
reducing discomfort but
should be used cautiously
because they can decrease
cough effort and depress
respirations

2. Increasing the
humidity will decrease the
viscosity of secretions. Clean
the humidifier before use to
avoid bacterial growth.
 COLLABORATIVE:

The respiratory therapist

plans oxygen therapy and
obtains a prescription from
the provider.

PHINMA UNIVERSITY OF ILOILO

COLLEGE OF ALLIED HEALTH SCIENCES
Nursing Department

NURSING CARE PLAN

NURSING
ASSESSMENT NURSING DIAGNOSIS PLANNING RATIONALE EVALUATION
INTERVENTIONS
SUBJECTIVE: Decreased Activity Tolerance SHORT TERM:
related to imbalance between
oxygen supply and demand After 3 hours of nursing
"Nabudlayan ako mag
as evidenced by verbal report intervention:
ginhawa" as verbalized by of difficulty of breathing. - Patient will demonstrate a
the patient. measurable increase in
tolerance to ADLs with
absence of dyspnea and
excessive fatigue.
- Patient will have vital signs
OBJECTIVE:
within acceptable range.
- Patient will verbalize
- Cough understanding of need to
- Loss of Appetite gradually increase activity
level and how to accomplish
Vital Signs: this.
BP: 120/70
T: 36
RR: 10 LONG TERM:
PR: 114
Spo2: 93% After 3 days of nursing
intervention:
- Patient will return to
baseline activity level.
- Patient will be completely
independent on performing
ADLs with no any signs of
dyspnea or fatigue.
- Patient will demonstrate
energy management
techniques.
- Patient will have a stable
vital signs.
INDEPENDENT:
- Monitor and record vital
signs.
- Assess the patient’s
baseline level of function and
activity tolerance.
- Determine response to
activity. Note reports of
dyspnea, increased
weakness and fatigue.
- Assess skin integrity
frequently.
- Assess nutritional status.
- Encourage the patient to
perform deep-breathing
exercises.
- Perform range of motion
(ROM) exercises.
- Pace activity for patient.
- Encourage the patient to
have adequate rest and sleep
as needed. Encourage
- To obtain baseline data.
- Using a standardized tool
such as the Functional
Independence Measure (FIM)
can provide a baseline of
function and activity tolerance
and can help determine the
appropriate interventions and
monitor the patient’s
progress.
- Establishes patient’s
capabilities and needs and
facilitates the choice of
interventions.
- Patients with decreased
activity level or intolerance to
activity are at an increased
risk of developing pressure
ulcers. Assess skin frequently
to prevent skin breakdown.
- Nutritional needs are
important because they
provide an energy source to
engage in activities.
-Deep-breathing exercises
can help reduce stress and
when used together with a
spirometer can help clear
secretions from the lungs.
- Regular exercise maintains
muscle strength, flexibility,
and joint and tendon
alignment. Over time,
repeated exercises help
increase tolerance, which is
vital to perform ADLs.
- Effective coughing may
exhaust an already
compromised patient. Fatigue
may be a contributing factor
to ineffective coughing.
- Rest is necessary for the
body to heal, but too much
rest can actually contribute to
Short term goals are met as
evidenced by:
- Patient demonstrates a
measurable increase in
tolerance to ADLs with
absence of dyspnea and
excessive fatigue.
- Patient's vital signs are
within acceptable range.
- Patient verbalized
understanding of need to
gradually increase activity
level and how to accomplish
this.
Long term goals are met as
evidenced by:
- Patient's return to baseline
activity level.
- Patient being completely
independent on performing
ADLs with no any signs of
dyspnea or fatigue.
- Patient demonstrates
energy management
techniques.
- Patient have a stable vital
signs:
T:36.2
RR: 16
PR: 77
SpO2: 95%
activities such as walking or
stretching.
-Assist patient to assume a
comfortable position for rest
and sleep.
- Assist with self-care
activities as necessary.
DEPENDENT:
-Provide supplemental
oxygen therapy as ordered.
- Treat pain as ordered.
- Provide appropriate
nutritional supplements when
indicated.
COLLABORATIVE:
- Consult a dietitian to meet
the patient’s nutritional needs.
fatigue. Encouraging the
patient to engage in gentle
activities can help improve
energy levels and prevent
deconditioning.
-The patient may be
comfortable with an elevated
head of the bed, sleeping in a
chair, or leaning forward on
an overbed table with pillow
support.
- Provide a progressive
increase in activities during
the recovery phase and
demand. Minimizes
exhaustion and helps balance
oxygen supply and demand.
- Patients with decreased
activity tolerance may
become short of breath with
activity and require additional
oxygen therapy in order to
maintain appropriate oxygen
saturation levels.
- Patients may be limited in
their ability to endure activity
due to pain (i.e. following a
surgery). Ensure patient
receives appropriate pain
medication in advance of
activity.
- If malnourished, it will be
more difficult for patient to
increase activity level
therefore, ensuring
appropriate nutrition is vital.
- Dietitians can adjust the
nutritional needs to the
patient’s situation. Adequate
intake of nutrients helps with
maintaining skin integrity,

- Refer the patient to a
rehabilitation specialist for
further fatigue management
strategies.
muscle strength, and immune
function.
- A rehab specialist can
provide additional support
and specialized insights for
the client to manage their
fatigue.