DAVAO DOCTORS COLLEGE

Gen.Malvar St, Davao City

Nursing Program
NURSING CARE PLAN GRADE:

Name of the patient: __________________________ Date of Admission: __________ Room: ______________

Age: ___ Sex: _____ Civil Status: _______ Chief Complaint: ________________________________
Religion:______________ Attending Physician: _____________________________
DATE & CUES NURSING DIAGNOSIS GOAL AND NURSING RATIONALE EVALUATION
TIME OBJECTIVES
INTERVENTION

At the end of 8 hours

January 27- Subjective: N/A Ineffective airway clearance At the end of 8 hours Independent: Elevate Oxygen delivery may be
of nursing
28 improved by upright
related to excessive, thickened of nursing intervention head of the bed, intervention patient
position and breathing
is able to;
Objectives: mucous membrane. the patient will able to; Encourage deep slow exercises to decrease
7:00am- airway collapse,
Persistent cough and or pursed lip breathing Patient display
3:00pm dyspnea and work of
improved ventilation
Wheezing,  Demonstrate as individually breathing.
and having an
Tachypnea improved tolerated. adequate oxygen
T: 36.8 ventilation and Monitor skin and Cyanosis may be No signs of any
P: 85 SCIENTIFIC BASIS adequate mucous membrane Peripheral in central abnormalities in
Inhales microorganism then lips or earlobes. breathing
R: 25 oxygen. coloration. Encourage
Fluids help to thin the
BP:120/70 transmitted to alveoli causing less  No signs of oral fluids intake No presence of
Secretions.
function or having impaired gas cough
respiratory Dependent:
exchange and inflammatory reaction
distress Administer IV fluids as
and mucus secretion causing
 No persistent necessary
Antibiotics are not re
ineffective airway clearance.
cough will be Administer Commended to treat
observe medications and Viral illnesses and can
(Medical surgical nursing 11th edition)
breathing treatments
cause patient to deve-
lop resistance over time
per facility protocol
Antiviral medications
like Ribavirin are given
for the viral infection

Reminder: Please provide references for your scientific basis discussion and for every rationale. Follow APA 6th ed. Guidelines to in-tact citation and writing preferences
BSN/DTS/KMS/2019 Name: Jerremy John K. Luque Clinical Instructor: _________________________