Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation
Subjective: Ineffective airway Short-term Goal: Independent: - Assessing the rate, After 5hrs of nursing
Ms. Chiz Mosa has clearance related to after 4-5hrs of - Assess the rate of depth, and intervention the
had “chest cold” for productive cough as nursing intervention the respiratory movement of the patient should be:
2 weeks and has evidence by labor the patient should be rhythm, depth of the respiratory.
been experiencing respiration. able breath properly respiratory, chest
shortness of breath without experiencing movements, and use - The position of the
upon exertion. She shortness of breath. of accessory muscle. head should be - The patient should
has also developed - Change the elevated to prevent a be able to breath
an elevated positions frequently, backflow of the without having any
temperature elevate the head of cough difficulties in her
yesterday, and has the bed. lungs.
begun to experience - Observe the airflow,
“pain” in her “lungs”. noting if there are
Long-term Goal: Dependent: any problems with
After 1-2weeks the - Use of medication the breathing - She also learnt
patient’s prescribed such as sounds; breathing techniques
temperature should antibiotics, wheezes/cackles. to help with her rapid
Objective: return to normal expectorant, etc. breathings, thus
Elevated which is 36.1 C and making her
temperature, a having to no difficulty respiratory rate back
productive cough, breathing and Collaborative: to normal.
and rapid, labored respiration problems. - Consult to a
respirations. respiratory therapist
when experiencing
rapid respiratory
breathing.
NURSING CARE PLAN
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DRUG STUDY
Name of Drug Route and Dosage Mechanism of Action Adverse Reaction Nursing Consideration
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