NURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Independent:
Subjective: • Ineffective • Chronic • After 4 hrs. • Assist patient • Elevation of the • After 4 hrs.
airway obstructive Of nursing to assume head of the bed Of nursing
“Nahihirapan ako clearance pulmonary interventions, position of facilitates intervention
huminga” as related to disease the client will comfort, e.g., respiratory function s, the client
verbalized by the increased (COPD) is a demonstrate elevate head by use of gravity. was able to
patient. production of disease behaviors to of bed, demonstrate
secretions. characterized improve encourage behaviors to
Objective: by airflow airway patient to lean improve
limitation that clearance. on overbed airway
• Use of is not fully e.g. cough table or sit on clearance.
accessory reversible. Air effectively the edge of e.g. cough
muscle. flow limitation and the bed. effectively
is usually expectorate • Keep • Precipitators of and
• Dyspnea progressive secretions. environmental allergic type or expectorate
and pollution to a respiratory secretions.
• Productive associated minimum, reactions that can
cough with an e.g., dust, trigger or
inflammatory smoke and exacerbate onset
• V/S taken as response in feather of acute episode.
follows: the lungs pillows,
stimulated by according to
T: 36.7 irritants. individual
P: 57 Common situation
R: 25 cause of • Encourage or • Provides patient
Bp: 100/80 COPD is assist with with some means
cigarette pursed lip to cope or control
smoking, air breathing dyspnea and
pollution, exercises. reduce air trapping.
allergens and • Observe • Coughing is most
infections that characteristics effective in an
may also act of cough like upright position or
as irritants. persistent or head down position
hacking or after chest
moist. Assist percussion.
with measures
to improve
effectiveness
o cough effort.
Dependent:
• Administer • A variety of
medication as medications may
prescribed by be used to
the physician. decrease mucus
and to improve
respiration.
• Provide • Humidity helps
supplemental reduce viscosity of
humidification secretions,
like nebulizer. facilitating
expectoration, and
may reduce or
prevent formation
of thick mucus
plugs in
bronchioles.