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Anthony’s College
San Jose, Antique
Nursing Department
NAME:R.D.R.
CC: Difficulty of Breathing NURSING CARE PLAN
CUES NURSING RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE: Ineffective airway Inability to clear Short term goal: INDEPENDENT:
“nabudlayan gawa ako clearance related secretions or Encourage deep Deep breathing After 8 hours of nursing
mag ginhawa” as to the increased obstructions from the After 8 hours of nursing breathing promotes intervention, goal partially met.
verbalized by the patient. production of respiratory tract to intervention, secretions exercises oxygenation The patient was able to
before controlled Demonstrate coughing
respiratory maintain a clear will be mobilized, Assist patient in
coughing.
secretions airway. airway patency will be coughing and deep breathing
To improve
OBJECTIVE: maintained free of exercises exercise every 1-2 hours
productivity of
Rapid breathing secretions, as Increase fluid the cough.
during the day.
Cough with yellow evidenced patient’s intake, as Adequate fluid Client’s respiratory rate
sputum production ability to effectively appropriate. intake enhances is within normal range
Crackles sound cough out secretios, Monitor liquefaction of (RR-20)
during breathing clear lung sounds, and rate,rythm and pulmonary Inspiratory crackles can
Dyspnea uncompromised effort of secretions and still be heard at the
VS taken as respiratory rate. respirations. faciliutates lower lobe.
expectoration of Cough continues to be
follows: Assist patient
mucus. productive.
T – 36.6oC into moderate
Provides a basis
P – 88bpm high back rest for evaluating
RR – 28cpm position. adequacy of
BP – 120/80mmHg DEPENDENT: ventilation.
Administer To promote
ordered drainage of
medications such secretions and
as mucolytic better lung
agents. expansion
To help loosen
and clear the
mucus from the
airways(mucolyti
cs).