Nursing Care Plan

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Acute pain r/t • After 4 hours of Independent: • Lowers diaphragm, • After 4 hours of
“Masakit ang dibdib localized inflammation nursing intervention • Elevate head of the promoting chest nursing intervention
ko” as verbalized by and persistent cough. the patient will bed, change position expansion and patient was able to
patient. display frequently. expectoration of display patent airway
patent airway with • Assist patient with secretions. with breath sounds
Objective: breath sounds deep breathing • Deep breathing clearing and absence
· Use of accessory clearing and absence exercises. facilitates maximum of dyspnea.
muscle. of dyspnea. • Demonstrate or expansion of the
· Dyspnea help patient learn to lungs and smaller
· Fatigue. perform activity like airways.
splinting chest and • Coughing is a
effective coughing natural self cleaning
while in upright mechanism. Splinting
position. reduces chest
• Force fluids to discomfort, and an
atleast 3000 ml per upright position favors
day and offer warm, deeper, more forceful
rather cough effort.
than cold fluids. • Fluids especially
warm liquids aid in
Collaborative: mobilization and
• Administer expectoration of
medications as secretions.
prescribe: mucolytics • Aids in reduction of
or expectorants. bronchospasm and
• Provide mobilization of
supplemental fluids. secretions.
• Fluids are required
to replace losses
and aid in mobilization
of secretions.