NURSING CARE PLAN

GENERAL OBJECTIVE
To facilitate the maintenance of oxygen
supply to all body cells

SUBJECTIVE CUES
As verbalized by the client:
Hindi ko mayo kaginhawa.
Nabudlayan ko maginhawa.
As verbalized by the folks:
Gakabugtaw siya kung gab e nga daw ginakulang
sang hangin.

OBJECTIVE CUES

Use of accessory muscles noted

Fatigability noted
Rapid, shallow breathing noted
Respiratory rate of 38-50 cpm noted
With O2 @ @L/min via nasal cannula
IVF PNSS 1L @ 80cc/hr
With pulse oximeter
With CTT drainage at mid-axillary line

OTHERS
CXR: collapsed R. lung with marked
pneumothorax, multiple small bullae in the
collapsed R. lung, suggest apico-lordotic view.
(August 3, 2015)
ABG RESULTS:
-pCO2: 27.3
(35-45mmHg)
-pO2: 75
(80-100 L)
-HCO2: 16.3
(22-26 L)
-BE: -7.2
(-2-2 L)

OTHERS
Hematology lab results:
-Hct: 0.32
(0.37-0.47 L)
-WBC: 13
(5-10x10^9/L)
-Segmenters: 82 (50-70%)
-Lymphocyte: 11 (25-40%)

NURSING
DIAGNOSIS

RATIONALE

SPECIFIC OBJECTIVES

Ineffective
airway
clearance
related to
secretions in
in bronchi 2o
to CAP-MR

Communityacquiredpneumonia(CAP) is
adiseasein which individuals
who have not recently been
hospitalized
develop
aninfectionof
thelungs(pneumonia).

CAP is a common illness and

can affect people of all ages.
CAP often causes problems
like difficulty in breathing,
fever,chest pains, and a
cough. CAP occurs because
the areas of the lung which
absorb oxygen (alveoli) from
the atmosphere become filled
with fluid and cannot work
effectively

Within 28 hours of rendering

nursing care, the client will
be able to:

Breathe without using

accessory muscles.
Demonstrate proper
breathing exercises

NURSING INTERVENTIONS

RATIONALE

Independent:
-Monitor V/S

- Position client to semi-fowlers for

optimal breathing pattern.

- Instruct and/or change clients

position (turn every 2hrs).

-Assess respirations; note quality,

rate, pattern, depth, flaring of
nostrils,

- Have a baseline of data.

- To promote better lung expansion

and improved air exchange.

- To facilitate secretion movement

and drainage.

- Abnormality indicates respiratory

compromise
-To prevent fatigue

-Promote energy conservation

techniques

NURSING INTERVENTIONS

RATIONALE

Independent:
-Demonstrate proper and teacher
proper breathing exercises.

- Teach client and SO about

environmental factors that can
precipitate respiratory problems.

- To enhance respiration

- To limit impact on client's breathing.

Collaborative:
- Provide O2

- Administer medications as ordered,

noting effectiveness and side effects.

- CTT insertion

- To increase oxygenation

- To prevent further complications

- To drain excess air or fluid from the

interstitial space.

- Monitor laboratory results

- To take note of any abnormalities

EVALUATION
Goal is partially met.

After 28 hours of rendering effective nursing care, the client was able to:
Demonstrate proper breathing exercises.
The clients respiratory rate decreased from 38 cpm to 30 cpm.