NURSING CARE PLAN
General Objective: To promote optimal activity: exercise, rest, sleep
 Assessment            Nursing         Rationale           Specific           Nursing           Rationale        Evaluation
                      Diagnosis                           Objectives        Intervention
Subjective          Activity          Coughing is      Within 4 hours     Independent                          After 4 hours
Cues:               intolerance       the body's       of nursing         -Evaluate           -Establishes     of nursing
Ga ubo man         related to        way of           Interventions      patients           patients        interventions,
ko gyapon. Ga       exhaustion        removing         the patient will   Respons e to        capabilities     the patient was
untat2x akon                                                              activity.           or needs and
                    associated        foreign          be able to                                              able to
tulog sa
                    with              material or      demonstrate a                          facilitates      demonstrate a
Gabi. As
                    Interruption in   mucous from      measurable                             choice of        measurable
verbalized by
the patient.        usual sleep       the lungs        increase in                            interventions.   increase in
                    pattern           and throat.      tolerance in                                            tolerance in
                    secondary to      The two          activity with                          -Reduces         activity with
Objective           Cough.            general          decrease RR of     -Provide a quiet    stress and       decrease RR of
Cues:                                 classification   16-20 cpm.         environment and     excess           20 cpm from 24
*Productive                           s of cough                          limit visitors      stimulation,     cpm.
cough noted                           are                                 during acute        promoting
with whitish                                                              phase.              rest.
                                      productive
phlegm.
                                      coughs
*tired and
                                      (producing                          -Elevate head       -These
sleepy eyes
                                      phlegm or                           and                 measures
noted.
*Capillary refill                     mucous from                         encourage           promotes
of 2 seconds.                         the lungs)                          frequent            maximal
Vital signs:                          and                                 position changes,   inspiration,
*Temp  360C                          nonproducti                         deep breathing      enhance
(36.5-37.50C)                         ve coughs                           and                 expectoration
*CR  82 bpm                          (dry and not                        effective           of
(60-100 bpm)                          producing                           coughing.           secretions to
*RR  24 cpm                                                                                  improve
                                      any mucous
(12-20 cpm)
                                      or phlegm).                                             ventilation.
*BP  110/80
mmhg      Coughs are
(120/80   also divided                       -Facilitates
mmhg)     into acute      -Encourage         healing
          (less than 3    adequate rest      process and
          weeks'          balanced with      enhances
          duration)       moderate           natural
          and chronic     activity.          resistance.
          (more than      Promote
          three weeks'    adequate
          Duration).      nutritional        - Fluids
          Acute cough     intake.            especially
          is most often                      warm liquids
          caused by       -Encourage         aid in
          the common      adequate fluids    mobilization
          viral upper     to                 and
          respiratory     at least 3000 ml   expectoration
          tract           per day and        of secretions.
          Infection.      offer warm,
          Patient H.N.,   rather than cold
          was not able    fluids.
          to have a
          good sleep      Collaborative    -Aids in
          at night        -Administer      reduction of
          because of      medications as   bronchospasm
          cough           prescribe:       and
          disturbances    Fluimucil        mobilization
          in time of      (mucolytic)      of secretions.
          sleep           600mg BID 1 tab, Exerts
          resulting to    P.O.             mucolytic
          sleepy and                       action through
          tired eyes as                    its free
          seen in                          sulfhydryl
          patient.                         group which
opens up the
disulfide bonds
in the
mucoproteins
thus lowering
mucous
viscosity.