PHINMA-UNIVERSITY OF ILOILO

COLLEGE OF ALLIED HEALTH SCIENCES

Nursing Department

NURSING CARE PLAN

NURSING NURSING
ASSESSMENT PLANNING RATIONALE EVALUATION
DIAGNOSIS INTERVENTIONS

SUBJECTIVE: Ineffective Breathing SHORT TERM: INDEPENDENT: INDEPENDENT: Short term goals are met as
Pattern secondary to evidenced by:
- "Nabudlayan ako mag Pneumonia as evidenced After 4 hours of nursing 1. Monitor and document 1. To detect early signs of
ginhawa," as verbalized by coughing, dyspnea, and intervention: respiratory rate and depth at respiratory compromise. - Patient exhibited improved
by the client. verbalization of the client, least every 4 hours. breathing pattern.
- Patient will exhibit 2. Unusual breathing
“nagbudlayan ako mag improved breathing pattern. 2. Observe breathing patterns patterns may imply an - Patient demonstrated deep
ginhawa.” underlying disease process breathing exercises to establish
- Patient will demonstrate 3. Auscultate breath sounds at or dysfunction. normal respiration.
deep breathing exercises to least every 4 hours.
establish normal respiration. 3. Is to detect decreased or - Patient obtained respiratory rate
4. Place patient with proper adventitious breath sounds. within established limits.
- Patient will obtain body alignment for maximum
OBJECTIVE: respiratory rate within breathing pattern. 4. A sitting position permits
established limits. maximum lung excursion
- BP: 120/70 5. Perform coughing and deep and chest expansion. Long term goals are met as
breathing exercises. evidenced by:
- T: 36 °C 5. These techniques promote
6. Encourage frequent rest deep inspiration, which - Patient maintains an effective
- RR: 10 periods and teach the patient to breathing pattern, as evidenced by
LONG TERM: increases oxygenation and
pace activity. prevents atelectasis. relaxed breathing at normal rate
- PR: 114
After 2 days of nursing and depth and absence of dyspnea.
- SPO2: 93 intervention: 6. Extra activity can worsen
shortness of breath. - Patient maintains respiratory rate
DEPENDENT: within 12-20 breaths per minute.
- Patient will maintain an
effective breathing pattern, 1. Antibiotics as prescribed. - Patient demonstrate deep
Cough
as evidenced by relaxed DEPENDENT: breathing.
breathing at normal rate and 2. Administer oxygen as
Ronchi sounds upon
depth and absence of ordered. 1. It works by stopping
auscultation dyspnea. the growth of
bacteria.
Difficulty of breathing - Patient will maintain COLLABORATIVE: 2. To promote
respiratory rate within 12-20 oxygenation.
Chest pain breaths per minute. 1. Collaborate with the
Respiratory therapist and
-Patient will demonstrate attending physician to address
deep breathing exercises. the ineffective breathing COLLABORATIVE:
pattern.
Teaching of deep breathing
and coughing exercises, and
prescription of preferred
medication for difficulty of
breathing
 PHINMA-UNIVERSITY OF ILOILO
COLLEGE OF ALLIED HEALTH SCIENCES
Nursing Department

NURSING CARE PLAN

NURSING NURSING
ASSESSMENT PLANNING RATIONALE EVALUATION
DIAGNOSIS INTERVENTIONS

SUBJECTIVE: Ineffective Airway SHORT TERM: INDEPENDENT: INDEPENDENT: Short term goals are met as
Clearance secondary to evidenced by:
"Nabudlayan ako mag pneumonia as evidence by After 8 hours of nursing 1. Assess the rate, rhythm, and 1. Tachypnea, shallow
ginhawa" as verbalized. coughing, dyspnea and interventions: depth of respiration, chest respirations and
ronchi sounds upon movement, and use of asymmetric chest
accessory muscles. movement are Respiratory rate is within normal
auscultation range.
Patient will frequently present
identify/demonstrate because of the
behaviors to achieve airway 2. Elevate the head of the bed discomfort of
clearance. and change position frequently. moving the chest Demonstrate behaviors achieving
wall and fluid in the airway clearance.
lung due to a
compensatory
OBJECTIVE: Patient will display/maintain 3. Teach and assist the patient
response to airway Maintained a patent airway with
a patent airway with breath with proper deep-breathing
obstruction. Altered breath sounds clearing as evidence
- BP: 120/70 sounds clearing; absence of exercises. Demonstrate proper
breathing patterns of absence of dyspnea
dyspnea splinting of the chest and
- T: 36 °C may occur together
effective coughing while in an
with accessory
- RR: 10 upright position. Encourage the
muscles to increase
Patient's respiratory rate patient to do so often.
chest excursion to
- PR: 114
will be in normal range facilitate effective
- SPO2: 93 breathing.

2. To lower the
4.Assist and monitor effects of Long term goal was met as
diaphragm and
Cough nebulizer treatment and other evidenced by:
promote chest
respiratory
Ronchi sounds upon expansion, aeration
of lung segments,
auscultation LONG TERM: mobilization, and Maintained a patent airway with
expectoration of breathing sounds clearing as
Difficulty of breathing After 2 days of nursing secretions. evidence by absence of dyspnea.
intervention, the patient will:
Chest pain DEPENDENT:

1. Administer medications such 3. Deep breathing

Maintain patent airway with as exercises facilitate
breathing sounds clearing as the maximum
evidence by absence of Mucolytics, Expectorants,
expansion of the
dyspnea. Bronchodilators and Analgesics.
lungs and smaller
airways and improve
the productivity of
2. Use humidified oxygen or cough.
humidifier at the bedside.
-Coughing is a reflex and a
natural self-cleaning
mechanism that assists the
COLLABORATIVE:
cilia in maintaining patent
1. Consulting with a respiratory airways. It is the most
therapist when the patient has helpful way to remove most
deteriorating oxygen saturation secretions.
levels.
-Splinting reduces chest
discomfort and an upright
position favors deeper and
more forceful cough effort
making it more effective.

4. Nebulizers humidify
the airway to thin
secretions and
facilitate liquefaction
and expectoration of
secretions.
DEPENDENT:

1. Mucolytics increase or
liquefy respiratory
secretions.

Expectorants increase
productive cough to clear
the airways by liquefying
lower respiratory tract
secretions and reducing their
viscosity.

Bronchodilators are
medications used to
facilitate respiration by
dilating the airways.

Analgesics are given to

improve cough effort by
reducing discomfort but
should be used cautiously
because they can decrease
cough effort and depress
respirations

2. Increasing the
humidity will decrease the
viscosity of secretions. Clean
the humidifier before use to
avoid bacterial growth.
 COLLABORATIVE:

The respiratory therapist

plans oxygen therapy and
obtains a prescription from
the provider.

PHINMA UNIVERSITY OF ILOILO

COLLEGE OF ALLIED HEALTH SCIENCES
Nursing Department

NURSING CARE PLAN

NURSING
ASSESSMENT NURSING DIAGNOSIS PLANNING RATIONALE EVALUATION
INTERVENTIONS
SUBJECTIVE: Decreased Activity Tolerance SHORT TERM: INDEPENDENT:
related to imbalance between - Monitor and record vital - To obtain baseline data. Short term goals are met as
oxygen supply and demand After 3 hours of nursing signs. evidenced by:
"Nabudlayan ako mag
as evidenced by verbal report intervention: - Assess the patient’s - Using a standardized tool - Patient demonstrates a
ginhawa" as verbalized by of difficulty of breathing. - Patient will demonstrate a baseline level of function and such as the Functional measurable increase in
the patient. measurable increase in activity tolerance. Independence Measure (FIM) tolerance to ADLs with
tolerance to ADLs with can provide a baseline of absence of dyspnea and
absence of dyspnea and function and activity tolerance excessive fatigue.
excessive fatigue. and can help determine the - Patient's vital signs are
- Patient will have vital signs appropriate interventions and within acceptable range.
OBJECTIVE:
within acceptable range. monitor the patient’s - Patient verbalized
- Patient will verbalize progress. understanding of need to
- Cough understanding of need to - Determine response to - Establishes patient’s gradually increase activity
- Loss of Appetite gradually increase activity activity. Note reports of capabilities and needs and level and how to accomplish
level and how to accomplish dyspnea, increased facilitates the choice of this.
Vital Signs: this. weakness and fatigue. interventions.
- Assess skin integrity - Patients with decreased
BP: 120/70
frequently. activity level or intolerance to Long term goals are met as
T: 36 activity are at an increased evidenced by:
RR: 10 LONG TERM: risk of developing pressure - Patient's return to baseline
PR: 114 ulcers. Assess skin frequently activity level.
Spo2: 93% After 3 days of nursing to prevent skin breakdown. - Patient being completely
intervention: - Assess nutritional status. - Nutritional needs are independent on performing
- Patient will return to important because they ADLs with no any signs of
baseline activity level. provide an energy source to dyspnea or fatigue.
- Patient will be completely engage in activities. - Patient demonstrates
independent on performing - Encourage the patient to -Deep-breathing exercises energy management
ADLs with no any signs of perform deep-breathing can help reduce stress and techniques.
dyspnea or fatigue. exercises. when used together with a - Patient have a stable vital
- Patient will demonstrate spirometer can help clear signs:
energy management secretions from the lungs. T:36.2
techniques. - Perform range of motion - Regular exercise maintains RR: 16
- Patient will have a stable (ROM) exercises. muscle strength, flexibility,
PR: 77
vital signs. and joint and tendon
alignment. Over time, SpO2: 95%
repeated exercises help
increase tolerance, which is
vital to perform ADLs.
- Pace activity for patient. - Effective coughing may
exhaust an already
compromised patient. Fatigue
may be a contributing factor
to ineffective coughing.
- Encourage the patient to - Rest is necessary for the
have adequate rest and sleep body to heal, but too much
as needed. Encourage rest can actually contribute to
activities such as walking or fatigue. Encouraging the
stretching. patient to engage in gentle
activities can help improve
energy levels and prevent
deconditioning.
-Assist patient to assume a -The patient may be
comfortable position for rest comfortable with an elevated
and sleep. head of the bed, sleeping in a
chair, or leaning forward on
an overbed table with pillow
support.
- Assist with self-care - Provide a progressive
activities as necessary. increase in activities during
the recovery phase and
demand. Minimizes
exhaustion and helps balance
oxygen supply and demand.

DEPENDENT:
-Provide supplemental - Patients with decreased
oxygen therapy as ordered. activity tolerance may
become short of breath with
activity and require additional
oxygen therapy in order to
maintain appropriate oxygen
saturation levels.
- Treat pain as ordered. - Patients may be limited in
their ability to endure activity
due to pain (i.e. following a
surgery). Ensure patient
receives appropriate pain
medication in advance of
activity.
- Provide appropriate - If malnourished, it will be
nutritional supplements when more difficult for patient to
indicated. increase activity level
therefore, ensuring
appropriate nutrition is vital.

COLLABORATIVE:
- Consult a dietitian to meet - Dietitians can adjust the
the patient’s nutritional needs. nutritional needs to the
patient’s situation. Adequate
intake of nutrients helps with
maintaining skin integrity,
 muscle strength, and immune
function.
- Refer the patient to a - A rehab specialist can
rehabilitation specialist for provide additional support
further fatigue management and specialized insights for
strategies. the client to manage their
fatigue.