NURSING CARE PLAN
KEY ISSUES SCIENTIFIC BASIS EXPECTED OUTCOME NURSING INTERVENTIONS RATIONALE
1. Ineffective Breathing Alteration on the patient’s Within 1 day of student Independent
Pattern related to O2:CO2 ratio due to nurse-patient interaction, Interventions:
decreased lung expansion decreased absorbed the patient/’s: 1. Assessed and To detect early
as manifested by dyspnea oxygen and poor gas Will not show signs of recorded signs of
with a respiratory rate of exchage related to respiratory distress respiratory rate respiratory
26cpm (April 15, 2019), presence to exudates on such as eupnea, and depth at least compromise.
and use of accessory the alveolar spaces causes dyspnea every 4 hours.
muscles noted. the body to cope by will show RR within
increasing respiratory rate normal values ( 12- 2. Auscultated To detect
or by hyperventilation. 20cpm) breath sounds. adventitious
The increase in will be able to sleep breath sounds;
respiratory rate is elicited and rest between report changes.
to cause an increase in interventions
the tidal volume of air Patient will have 3. Assisted patient These measures
that in inspired in order to enhanced knowledge to a comfortable promote comfort,
absorb more oxygen. The on what to do when position, such as chest expansion,
increase in respiratory she manifest signs of by supporting and ventilation of
rate may need the difficulty in breathing. upper extremities basilar lung fields.
assistance of accessory with pillows,
muscle that would be providing over
evident by the rising and bed table with a
falling of the shoulders pillow to lean on,
during inspiration and and elevating
expiration. head of bed.
4. Noted retractions These signify an
or flaring of increase in work
nostrils. of breathing.
5. Monitored for Restlessness is an
changes in early sign of
orientation, hypoxia.
increased
restlessness,
anxiety, and air
hunger.
6. Taught patient These measures
about pursed-lip allow patient to
breathing, participate in
abdominal maintaining
breathing, and health status and
performing improve
relaxation ventilation
techniques.
7. Instructed patient to promote lung
SO in performing expansion
DBE and its
purpose.
Collaborative:
1. Salbutamol + 2cc aids in reduction
NSS of bronchospasm
nebulizatution q and mobilization
8H of excretions.
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. INEFFECTIVE AIRWAY Mucus production in the After 1 day of student 1. Assessed present For baseline data
CLEARANCE related to airways is normal. nurse – patient state
tracheobronchial Without it, airways interaction the patient/’s:
secretions secondary to become dry and Will be able to cough 2. Elevated patient’s to promote
pneumonia as manifested malfunction. But effectively. head of bed proper ventilation
by presence of productive sometimes the mucus is Will not be in
cough with whitish produced in excess and Respiratory distress 3. Monitored client’s to know if there’s
sputum and presence of changes in nature. This Minimize adventitious respiratory further
wheezing upon results in the urge to sound secretions. Such abnormalities
auscultation cough and expectorate Will be abe to as the color and
this mucus as sputum. expectorate without consistency
Sputum expectoration is difficulty aid in
not normal and there is 4. Encouraged patient expectorating
always an underlying to cough sputum
pathological cause.
for expansion of
5. Performed Deep lungs and aid in
breathing expectorating the
exercises sputum
to help loose
6. Performed Chest secretions
tapping and
advised SO to
perform chest tap
A variety of
7. Instituted respiratory
respiratory therapy
therapy treatments may
treatments such be used to open
as nebulizer as constricted
needed airways and
liquefy secretions.
Collaborative
Interventions:
1. Gave medications
for the loosening
of sputum.
N-acetylcysteine
(Fluimucil) 600
mg 1 tab
