VISION Republic of the Philippines MISSION
A premier university in CAVITE STATE UNIVERSITY Cavite State University shall provide
historic Cavite recognized excellent, equitable and relevant
Don Severino Delas Alas
for excellence in the educational opportunities in the arts,
development of morally Campus science and technology through quality
upright and globally Indang, Cavite instruction and relevant research and
competitive individuals. development activities. It shall produce
College of Nursing professional, skilled and morally upright
individuals for global competitiveness.
NURSING CARE PLAN
Name of Patient (initials): A.G. Date: 5/15/23
Age/Sex: F Diagnosis: Ineffective airway clearance related to loss ciliary
action, increased amount of secretion and increased airway
resistance as evidenced by infection to tonsils and pharynx
NURSING
ASSESSMENT NURSING DIAGNOSIS PLANNING RATIONALE EVALUATION
INTERVENTION
Subjective Data: Ineffective airway After 5 hours of effective 1. Auscultate lungs for 1. Abnormal breath After 5 hours of effective
“inuubo parin po” as clearance related to lossnursing intervention the presence of normal sounds can be nursing intervention the goal
verbalized by the ciliary action, increasedclient will be able to; or heard as fluid and was met the client able to;
guardian. amount of secretion and 1. maintain clear, open adventitious mucus accumulate. 1. maintain clear, open
increased airway airways as evidence breath sounds This may airways as evidence
resistance as evidenced by by normal indicate by
infection to tonsils and breath ineffective airway normal breath
pharynx sounds, normal rate clearance. sounds, normal rate
and depth of 2. Teach the patient the 2. The most and depth of
respirations, and proper ways of convenient way to respirations, and
ability to effectively coughing and remove most ability to effectively
Objective Data: cough up breathing. (e.g., take secretions is cough up
secretions after a deep breath, hold coughing. So, it is secretions after
V/S: T - 36.3 treatments and deep for 2 seconds, and necessary to treatments and deep
PR – 116 breaths. cough two or three assist the patient breaths.
RR - 37 2. demonstrate times in during this activity. 2. demonstrate
increased air succession). Deep breathing, increased air
(+) cough exchange. on the other hand, exchange.
promotes
oxygenation before
controlled coughing.
3. Encourage patient to 3. Fluids help
increase fluid minimize mucosal
intake to 1 liter per drying and
day within the limits maximize ciliary
of cardiac reserve action to move
and renal function. secretions.
4. Give medications
as prescribed, 4. A variety of
such as antibiotics, medications are
mucolytic agents, prepared to
bronchodilators, manage specific
expectorants, noting problems. Most
effectiveness and promote clearance
side effects. of airway
secretions and may
5. Instruct patient reduce airway
guardian about the resistance.
need for adequate 5. Hydration facilitates
fluid intake even easy
after hospital elimination of
discharge. secretions.
6. Perform CPT after
nebulizer 6. To properly
expectorate the
phlegm
Submitted by: Aeron Waleed A. Palileo Submitted to: Vanessa Rodil RN
Year/Section/Group: BSN 4-2/Group 2 Date:
VISION Republic of the Philippines MISSION
A premier university in CAVITE STATE UNIVERSITY Cavite State University shall provide
historic Cavite recognized excellent, equitable and relevant
Don Severino Delas Alas
for excellence in the educational opportunities in the arts,
development of morally Campus science and technology through quality
upright and globally Indang, Cavite instruction and relevant research and
competitive individuals. development activities. It shall produce
College of Nursing professional, skilled and morally upright
individuals for global competitiveness.
NURSING CARE PLAN
Name of Patient (initials): A.G. Date: 5/15/23
Age/Sex: F Diagnosis: Readiness for Enhanced Comfort as evidenced by
showing no signs of difficulty in breathing
NURSING
ASSESSMENT NURSING DIAGNOSIS PLANNING RATIONALE EVALUATION
INTERVENTION
Readine
Subjective Data: After 4 hours of nursing 1. Assessed general 1. To get a general After 4 hours of nursing
“Di na po siya masyado interventions, the patient health Status. understanding of the intervention the goal was
inuubo” as stated by the should be calm, well-fed, state of the patient’s met as evidenced by patient
guardian and well-rested. health and well- is calm and well fed and
Objective Data:
ss for 2. Monitored V/S. 2.
being. sleeping soundly during the
To help assess the shift.
physical health of
V/S: T - 36.3
PR – 116
RR - 37
Enhance the patient, give
clues to possible
diseases, and show
d
progress toward
recovery.
(-) cough 3. Provided a calm 3. To promote rest and
(-) colds environment. healing
Comfort
Readiness for Enhanced
Comfort as evidenced by
showing no signs of
difficulty in breathing
Submitted by: Aeron Waleed A. Palileo Submitted to: Vanessa Rodil RN
Year/Section/Group: BSN 4-2/Group 2 Date:
