Name: C.G.R St.

Anthony’s College
Age: 2 y.o San Jose, Antique
Diagnosis: MR Pneumonia Nursing Department

NURSING CARE PLAN

CUES NURSING RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Time: 8:00am Ineffective Ineffective Airway General Objectives: Independent: After 8 hours of nursing
Date: 02/28/2020 Airway Clearance is After 8 hours of 1. Auscultate breath 1. To ascertain status intervention patient has
Subjective: Clearance defined as the nursing interventions, sound and note progress maintain airway patency and
“grabe gid ubo ka bta related to inability to clear patient will be able to 2. Position client to semi 2. &3. To maintain able to expectorate
ko tapos nabudlayan retained secretions or verbalize fowler’s positions. open airway and secretions.
tana mg ginhanwa kag secretions. obstructions from understanding of cause 3. Elevate head of the bed decrease Goal partially met.
duro plemas na”as the respiratory and therapeutic 4. Kept environment diaphragm
verbalized by the tract to maintain a management regimen. allergen free pressure and
patient. clear airway. Use 5. Encourage deep increase drainage
Objective: this nursing Specific Objectives: breathing and coughing to lung field
 Coughing References: diagnosis guide to After 4 hours of reflexes. 4. To lessen irritants
noted formulate your nursing intervention 6. Encourage warm fluids that can further
 Presence of Doenges, M. E., ineffective Airway the patient will be able versus cold fluids irritate nasal
phlegm Moorhouse, M. Clearance care to: 7. Observe for signs of airway
 Orthopnea F. & Geissler- plan. Retained Maintain airway respiratory distress. 5. To expel excess
 Difficulty of Murr, A. C. secretion in the patency and secretions
breathing (2002). Nursing airway tract can demonstrate absence 6. Help liquefy
Care Plans: impair the of crackles sound and secretions
V/S taken as follows: Guidelines for ventilation of the able to expectorate 7. To prevent further
BP-130/80mmhg Individualizing patient. secretions. complications.
Patient Care, ed 8. Evaluate amount and 8. Excessive and/or sticky
T-36.5°c
6. Philadelphia: type of secretions being mucus can
PR-87cpm
F. A. Davis, pp produced make it difficult maintain
RR-26 bpm
118–120. effective airways,
O2sat-99%
especially if client has
impaired cough function,
is
very young or old,
 developmentally delayed,
References: has restrictive or
obstructive lung disease,
Doenges, M. E.,
or is
Moorhouse, M. F.
mechanically
& Geissler-Murr,
ventilated.
A. C. (2002).
Nursing Care
Plans: Guidelines
Dependent: 1. To relax smooth
for
1. Give expectorants, respiratory
Individualizing
anti-inflammatory musculature,
Patient Care, ed 6.
agents, reduce airway
Philadelphia: F. A.
bronchodilators and edema and
Davis, pp 118–
mucolytic agents as mobilize
120.
ordered. secretions.