NURSING CARE PLAN

ASSESSMENT DATA DIAGNOSIS RATIONALE PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective: Ineffective airway Inflammation of the lung After 1 hour of nursing 1. Assess and 1. Tachypnea is
“Madali laak kapoyun, clearance r/t Pneumonia parenchyma results to intervention the patient monitor usually present
napabulig nala ak kun as evidenced by O2sat of accumulation of will be able to: respiratory rate. to some degree
nabuhat or kun 93% secretion restricting 1. Maintain patent Note inspiratory- and may be
mabaktas tikadto ha CR” oxygen exchange and airway with to expiratory pronounced on
as verbalized due to the inflammation breath sounds ratio. admission,
bronchial constriction clear or clearing. during stress, or
Objective: occurs in which the 2. Demonstrate during
O2sat of 93% airway system narrows behaviors to concurrent acute
causing decreased improve airway infectious
passage of oxygen clearance process.
entering the lungs for Respirations may
utilization. be shallow and
rapid, with
prolonged
Source: Nursing Care expiration in
Plans pg. 272 comparison to
inspiration.

2. Auscultate 2. Some degree of

breath sounds. bronchospasm is
Note present with
adventitious obstructions in
breath sounds airway and may
such as wheezes, or may not be
crackles, or manifested in
rhonchi. adventitious
breath sounds,
such as
scattered, moist
crackles
(bronchitis); faint
sounds, with
expiratory
wheezes
 (emphysema); or
absent breath
sounds (severe
asthma).

3. Note presence 3. Respiratory

and degree of dysfunction is
dyspnea, for variable
example, reports depending on
of “air hunger,” the underlying
restlessness, process, for
anxiety, example,
respiratory infection, allergic
distress, and use reaction, and the
of accessory stage of
muscles. chronicity in a
client with
established
COPD.

4. Assist client to 4. Elevation of the

maintain a head of the bed
comfortable facilitates
position to respiratory
facilitate function using
breathing by gravity; however,
elevating the client in severe
head of bed, distress will seek
leaning on over- the position that
bed table, or most eases
sitting on edge of breathing.
bed. Supporting arms
and legs with
table, pillows,
and so on helps
reduce muscle
fatigue and can
 aid chest
expansion.

5. Encourage and 5. Provides client

assist with with some
abdominal or means to cope
pursed-lip with and control
breathing dyspnea and
exercises. reduce air-
trapping.

6. Increase fluid 6. Hydration helps

intake to 3000 decrease the
mL/day within viscosity of
cardiac secretions,
tolerance. facilitating
Provide warm or expectoration.
tepid liquids. Using warm
Recommend liquids may
intake of fluids decrease
between, instead bronchospasm.
of during, meals Fluids during
meals can
increase gastric
distention and
pressure on the
diaphragm.