NURSING CARE PLAN FOR INEFFECTIVE AIRWAY CLEARANCE

IMPLEMENTATION
ASSESSMENT DIAGNOSIS PLANNING EVALUATION
INTERVENTION RATIONALE

Subjective Data: Ineffective Within 8 hours of Independent: Goal Met.

 The patient airway nursing At the end of the 8
verbalized clearance interventions, the Encouraged the patient to Reduces secretion, which hours of nursing
”parang laging related to patient will maintain consistent facilitates expectoration interventions, the
may sumasabit excessive demonstrate hydration. and lowers the possibility patient is able to
na phlegm sa mucus effective of blockage. demonstrate effective
throat ko at hirap production and coughing and coughing a he
din talaga impaired cough expectoration of Educated the patient about Deep breathing exercises verbalized “medyo
huminga” reflex mucus, and will effective deep breathing help expand the nakakahinga nap o ako
secondary to report relief from exercises (e.g., pursed-lip lungs, improve ng maayos dahil
Objective Data: acute bronchitis dyspnea. breathing, diaphragmatic ventilation, and loosen nailalabas ko na po
 Rales breathing) mucus. yung phlegm.”
 Low Oxygen
saturation
Encourage the patient to sit Positioning the patient in
upright or in a semi- specific positions to allow
Fowler's position to gravity to assist in mucus
promote optimal lung drainage
expansion and facilitate
mucus drainage

An effective way to move

Educated the patient about mucus from the lungs and
the effective coughing airway as it is also less
techniques such as huff tiring and less forceful.
coughing
Dependent:
To alleviate and forestall
 Administered bronchospasm in
Bronchodilators, conditions such as asthma,
Salbutamol (asmacaire) chronic obstructive
1 nebule q4h pulmonary disease
(COPD), and reversible
airway diseases.
 NURSING CARE PLAN FOR IMPAIRED GAS EXCHANGE

IMPLEMENTATION
ASSESSMENT DIAGNOSIS PLANNING EVALUATION
INTERVENTION RATIONALE

Subjective Data: Impaired gas Upon the Independent: Goal Met.

The patient stated that exchange completion of an After the completion of
”hirap po akong related to 8-hour nursing This promotes a more 8 hour nursing
huminga, lalo nap o ineffective intervention, it is Advised the patient to effective and more intervention the patient
kapag nakahiga flatly sa breathing expected that sustain an erect posture or comfortable breathing shows an enhanced
bed.” pattern as the patient will elevate the bed's head pattern and to facilitate respiratory condition
evidenced by manifest (e.g., semi-fowler’s or lung expansion. and comfortable
Objective Data: tachypnea considerable fowler’s position) breathing as
 Orthopnea secondary to enhancement in manifested by a
 Tachypnea acute bronchitis their respiratory Promoted engagement in To promote lung respiratory rate of 18
 RR: 31 cpm condition, deep breathing exercises, expansion, mobilize cpm; as the patient
marked by a coughing maneuvers, and secretions, and improve verbalized that
discernible the utilization of incentive ventilation. “kaninang nakahiga ako
reduction in spirometry. po ako medyo maayos
breathing Provided education to the na po ang pag hinga
discomfort and a patient regarding the This provides awareness to ko.”
restoration of significance of upholding the patient about the
regular breathing optimal respiratory hygiene factors and underlying
patterns. practices, including cause that might trigger the
minimizing exposure to patient’s case. As well as
respiratory irritants. to provide
countermeasures in how to
combat such triggering
factors.
Dependent:

1. Administered
Salbutamol (asmacaire)
1 Neb q4h via To relieve bronchospasm
inhalation, as prescribed and improve airway
by the physician. patency and this is also an
effective way to deliver
medications that can help
to open up the airways or
loosen mucus.
 NURSING CARE PLAN FOR KNOWLEDGE DEFICIT

IMPLEMENTATION
ASSESSMENT DIAGNOSIS PLANNING EVALUATION
INTERVENTION RATIONALE

Subjective data: Hyperthermia Within 30 to 1 hour of Independent: Goal Met.

The patient’s mother related to nursing interventions,
articulated that “mainit infection as the patient will 1. Monitored vital Helps to assess the severity After 30 minutes to 1
po ang kili kili at ang evidenced by manifest a body signs and patient’s of hyperthermia and identify hour of nursing
noo niya po nung elevated body temperature within level of its early complications interventions, the
kinagabihan na” temperature normal range of 36.5 consciousness patient is able to
C – 37.5 C. regularly. manifest a body
temperature of 36.3 C.
Objective Data: By using a fan to blow
 Elevated body 2. Provided cooling directly onto the patient and
temperature (38. measures (e.g., also spraying or sponging,
6 C) tepid sponge bath, you can accelerate the rate
applying ice of evaporation and thereby
packs: to the lower the body temperature
groin, axillae, and more quickly.
neck)

To dispel common myths

and misconceptions about
3. Provided patient hyperthermia. For example,
education about some people believe that
the fever is always a good
misconceptions thing, or that it is necessary
regarding to "sweat out" a
 hyperthermia fever. These misconceptions
can lead to delays in
seeking treatment, which
can put patients at risk.

This will prevent

dehydration, which may
4. Encourage the worsen hyperthermia
patient to drink
plenty of fluids

Dependent: To help reduce fever and to

efficiently apply health care
5. Administered through collaboration
antipyretic drugs
Paracetamol (300
mg IV as ordered
by the physician.
To treat bacterial infection
and reduce fever.
 NURSING CARE PLAN FOR DISTURBED SLEEPING PATTERN

IMPLEMENTATION
NURSING
ASSESSMENT PLANNING EVALUATION
DIAGNOSIS
INTERVENTIONS RATIONALE

Subjective (S) Data: Disturbed Within an eight- Independent: Independent: Short Term Goal:
Sleeping Pattern hour timeframe
The patient verbalized “pag gabi related to the following nursing 1. Assessed and  Used to Goal met. After eight
nagigising ako, lalo na pag tuloy presence of cough interventions, the documented patient's determine usual hours of nursing
tuloy yung cough ko.” and dyspnea patient is will be sleep pattern. sleep patterns interventions, the patient
secondary to acute able to experience and provide was able to sleep
Objective (O) Data: bronchitis uninterrupted and comparative comfortably without any
comfortable sleep, baseline interruptions and
 Increased daytime naps accompanied by information. became more active and
heightened levels participative during
of activity and 2. Provided a quiet and  monitoring session.
increased This facilitates
peaceful environment better sleep and
participative
during sleep periods. rest.
cooperation and
active on
monitoring
sessions. 3. Advised the patient  By teaching the
effective coughing patient proper
techniques, such as huff coughing
coughing or controlled techniques, they
coughing, to minimize can effectively
the disturbance caused clear their
by coughing during airways and
sleep. reduce the
frequency and
intensity of
coughing
episodes during
sleep, allowing
for better sleep
quality.

Dependent

4. Administered
 NURSING CARE PLAN FOR INEFFECTIVE BREATHING PATTERN

IMPLEMENTATION
NURSING
ASSESSMENT PLANNING EVALUATION
DIAGNOSIS
INTERVENTIONS RATIONALE

Subjective (S) Data: Ineffective Within eight Independent: Independent: Goal met. After eight
Breathing hours of nursing hours of nursing
The patient verbalized “konting Pattern related to interventions, the Instructed the patient to Putting the patient interventions, the
lakad pa lang po eh ang bilis na inflammatory patient will be sit up straight or in a in particular patient is able to have
agad ng paghinga ko.” process along the able to have a semi-Fowler's position in postures so that a comfortable
respiratory tract normal order to foster better gravity can help breathing pattern as
Objective (O) Data: as manifested by respiratory rate of mucus drainage and with mucus he verbalized “di na po
tachypnea and 12 to 20 cpm, enhance lung expansion. outflow. ako nahihirapan
Vital Sign: restlessness and will verbalize huminga.” As
RR: 31 cpm secondary to relief from evidenced by
acute bronchitis tachypnea. respiratory rate of 17
 Dyspnea Instructed the patient to cpm.
 Restlessness maintain adequate This is to alleviate
hydration and fluid intake discomfort and to
facilitate a more
effective airway

Taught the patient about

effective deep breathing This promote and
exercises such as pursed- facilitate a better
lip breathing ventilation and
expand the lungs

Provided a calm, quiet,

and comfortable
This is to alleviate
ambience to the patient
stress of the
patient in order to
prevent
restlessness which
may result to
Dependent:
tachypnea
Administered
Dependent:
Bronchodilators,
Salbutamol (asmacaire) 1 To treat and