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    Nursing Care Plan: Subjective Data: Short Term Goal: Short Term Goal

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    Rheza
    The nursing care plan is for a patient with ineffective airway clearance due to increased pulmonary secretions. Short term goals include the patient understanding causative factors within 4 hours of interventions. Interventions include monitoring vitals, encouraging rest, increased fluids, and using a mask to avoid irritants. Long term goals include demonstrating improved airway clearance within 8 hours. Interventions include positioning changes, medication administration, PAI treatment, and a blenderized diet.

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    Nursing Care Plan: Subjective Data: Short Term Goal: Short Term Goal

    Uploaded by

    Rheza
    1K views1 page
    The nursing care plan is for a patient with ineffective airway clearance due to increased pulmonary secretions. Short term goals include the patient understanding causative factors within 4 hours of interventions. Interventions include monitoring vitals, encouraging rest, increased fluids, and using a mask to avoid irritants. Long term goals include demonstrating improved airway clearance within 8 hours. Interventions include positioning changes, medication administration, PAI treatment, and a blenderized diet.

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    care plan

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    Actual care plan

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    The nursing care plan is for a patient with ineffective airway clearance due to increased pulmonary secretions. Short term goals include the patient understanding causative factors within 4 hours of interventions. Interventions include monitoring vitals, encouraging rest, increased fluids, and using a mask to avoid irritants. Long term goals include demonstrating improved airway clearance within 8 hours. Interventions include positioning changes, medication administration, PAI treatment, and a blenderized diet.

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    Download as docx, pdf, or txt
    1K views1 page

    Nursing Care Plan: Subjective Data: Short Term Goal: Short Term Goal

    Uploaded by

    Rheza
    The nursing care plan is for a patient with ineffective airway clearance due to increased pulmonary secretions. Short term goals include the patient understanding causative factors within 4 hours of interventions. Interventions include monitoring vitals, encouraging rest, increased fluids, and using a mask to avoid irritants. Long term goals include demonstrating improved airway clearance within 8 hours. Interventions include positioning changes, medication administration, PAI treatment, and a blenderized diet.

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    PHINMA UNIVERSITY OF ILOILO

    COLLEGE OF ALLIED HEALTH SCIENCES


    Nursing Department

    NURSING CARE PLAN


    NURSING
    ASSESSMENT NURSING DIAGNOSIS PLANNING RATIONALE EVALUATION
    INTERVENTIONS
    Short term goal: Independent Short term goal:
    Subjective Data: Ineffective Airway After 4 hrs of nursing * Establish vapport * To gain trust After 4 hrs of nursing
    “Nabudlayan ang bata ko clearance related to interventions, the * Monitor vitalsign * To know baseline status interventions,the goal
    magginhawa" as increased production & patient will be able to * Encourage * To prevent situation that was met that the patient
    verbalized by the mother retained pulmonary oppurtunities for rest and will aggrevate the
    verbalize understanding able to verbalize
    of the patient. secretions as evidenced limit physical activities conditions
    causative factors that understanding causative
    * Increased fluid intake * Hydration can help
    by: allergerns like smoke, factors that allergerns
    2,000ml/day prevent one accumulation
    Objective Data: 1. RR:23cpm dust, fumes, feather like smoke, dust, fumes,
    of riscous secretion
    * V/S 2. Productive cough with pillows can contribute to * Assess the rate and feather pillows can
    clearance
    T: 36°C yellowish sticky phlegm ineffective airway depth of respiration contribute to ineffective
    * To monitor rapid
    PR: 64bpm 3. Labored breathing * Instruct patient to wear
    clearance breating or shallow airway clearance
    RR: 23 cpm 4. Nasal flaring is noted mask at all times to avoid
    Long term goal: respiration Long term goal:
    * Productive cough with causative factors * To avoid irritants that
    After 8 hrs of nursing After 8 hrs of nursing
    yellowish sticky phlegm * Elevate head of the bed can increased musuc
    interventions, the interventions, the goal
    and change position secretary production
    *Labored breathing patient will demonstrate was partially met that
    frequently which can interfere with
    * Nasal flaring is noted behaviors to improve the patient demonstrate
    Dependent: airway clearance
    airway clearance * Assist in administering behaviors to improve
    * Promotes expectoration
    medication airway clearance as
    cleansing or infection
    * Assist for PAI treatment * To promote deeper evidenced by:
    1. RR: 18cpm
    Collaborative: respiration and cough 2. expectorate secretions
    * Refer to dieticians * To ensure/ clear 3. unlabored breathing
    having blenderized diet maintain open airway and 4. nasal flaring is noted
    for the patient removal secretions
    * Appropriate mixture of
    food as well as balanced meal
    provides nutrients need
    PREPARED BY: ______________________________________

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