NURSING CARE PLAN

Name of Patient:

Age: Civil Status: Single Nationality: Occupation: NA

Date of Admission: Chief Complaint/ Diagnosis: Cough/Severe Pneumonia Sex: Male

PROBLEM/ HEAD
SCIENTIFIC NURSING NURSING SCIENTIFIC
CUES NURSING EVALUATION
EXPLANATION OBJECTIVE INTERVENTION EXPLANATION
DIAGNOSIS
Objective: Ineffective airway “Pneumonia is an After 3-4 hours of  Positioned client in  Upright position After 4 hours of
clearance related to inflammation of the nursing interventions, semi-Fowler’s position increases oxygenation nursing intervention,
 (+) crackles upon presence of secretions lung parenchyma, the patient’s to optimize respiration. and ventilation. It also the client was able to
auscultation of secondary to associated with respiration shall have allows maximum lung maintain patent
chest pneumonia. alveolar edema and improved and difficulty expansion. airway as evidenced
 Nasal flaring congestion that impair of breathing shall have by:
 Restlessness gas exchange. This been relieved.  Bronchodilators
accumulation is an decrease airway  Minimal sputum
 Presence of clear
obstruction in the resistance. production
watery discharge  Administered
smooth flowing of air in  Lessened nasal
from his nose salbutamol as
and out of the lungs. flaring
 Dyspnea prescribed by the
With this blockage a  RR=60 breaths per
 RR=88 breaths per physician.
patent airway is difficult minute
minutes  Instructed the
to maintain, this results
client’s significant  Lessened irritability
in decreased volume of
others the importance
inspired air resulting to
of maintain proper Nursing objective was
an impaired oxygen
nutrition, adequate met.
exchange within the
alveoli of the lungs. fluids, rest, and
behavioral pacing for
Resulting to a lower
oxygen supply for the energy conservation
and rehabilitation.
rest of the body.”

 Advised the client’s

significant others to
Fundamentals of identify and avoid
Nursing, 7th ed, Kozier et factors that can
al, pg. 1069-1070. exacerbate ineffective
airway clearance,
including known
allergens and
exposure to second
hand smoking.

Name of Student: Rating:

Year and Section: C.I. Signature: