Nursing Care Plan Submitted by: MEDINA, PATRICK LUIS F.
CRITERIA FOR EVALUATION
ACTION
DX:
• Auscultate breath sounds,
noting areas of decreased air-
flow or adventurous sounds
• Assess respiratory rate, depth.
Note use of accessory muscles,
pursed lip breathing and
inability to speak or converse
• Assess / routinely monitor skin
and mucous membrane
• Palpate for fremitus
• Monitor level of consciousness
or mental status. Investigate
changes
Nursing Care Plan
RATIONALE
• Noisy respiration, rhonchi and
wheezes are indicative of
retained secretions and airway
obstruction.
• Useful in evaluating the degree
of respiratory distress and / or
chronicity of the disease
process; tachypnea, shallow
respirations and asymmetric
chest movement are frequently
present because of discomfort
of moving chest wall and fluid
in lungs.
• Cyanosis may be peripheral
(noted in nail beds) or central
(noted around lips or earlobes).
Duskiness and central cyanosis
indicates advanced hypoxemia.
• Decrease of vibratory tremors
suggest fluid collection or air
trapping
• Restlessness and anxiety are
common manifestations of
hypoxia.
EVALUATION
Objectives are Fully Met if the
patient:
1. Will manifest stable and
normal vital signs (BP, RR, PR,
Temp)
2. Will manifest clear breath
sounds as manifested by
absence of crackles
3. Will cough effectively through
capability to expectorate all
accumulated secretions
4. will enumerate at least 2
management of cough
5. will adhere and comply to all
therapeutic regimens like
medication
Objectives Partially Met if the
patient:
1. Will manifest normal vital
signs (BP, RR, PR, Temp) but
unstable
2. Will manifest decrease breath
sounds
Submitted by: MEDINA, PATRICK LUIS F.
3. Will cough effectively through
capability to expectorate some
but not all of the accumulated