St.

Anthony’s College
San Jose, Antique
Nursing Department
NAME:R.D.R.
CC: Difficulty of Breathing NURSING CARE PLAN
CUES NURSING RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE: Ineffective airway Inability to clear Short term goal: INDEPENDENT:
“nabudlayan gawa ako clearance related secretions or  Encourage deep  Deep breathing After 8 hours of nursing
mag ginhawa” as to the increased obstructions from the After 8 hours of nursing breathing promotes intervention, goal partially met.
verbalized by the patient. production of respiratory tract to intervention, secretions exercises oxygenation The patient was able to
before controlled  Demonstrate coughing
respiratory maintain a clear will be mobilized,  Assist patient in
coughing.
secretions airway. airway patency will be coughing and deep breathing
 To improve
OBJECTIVE: maintained free of exercises exercise every 1-2 hours
productivity of
 Rapid breathing secretions, as  Increase fluid the cough.
during the day.
 Cough with yellow evidenced patient’s intake, as  Adequate fluid  Client’s respiratory rate
sputum production ability to effectively appropriate. intake enhances is within normal range
 Crackles sound cough out secretios,  Monitor liquefaction of (RR-20)
during breathing clear lung sounds, and rate,rythm and pulmonary  Inspiratory crackles can
 Dyspnea uncompromised effort of secretions and still be heard at the
 VS taken as respiratory rate. respirations. faciliutates lower lobe.
expectoration of  Cough continues to be
follows:  Assist patient
mucus. productive.
T – 36.6oC into moderate
 Provides a basis
P – 88bpm high back rest for evaluating
RR – 28cpm position. adequacy of
BP – 120/80mmHg DEPENDENT: ventilation.
 Administer  To promote
ordered drainage of
medications such secretions and
as mucolytic better lung
agents. expansion
 To help loosen
and clear the
mucus from the
airways(mucolyti
cs).