XI.

NURSING CARE PLAN

Nursing Goal/Objective Nursing

Analysis Rationale Evaluation
Problem/Cues s Interventions
Subjective data: Increased Goal: Goal met.
amount and After the 8-hour
Patient verbalized viscosity of shift the client’s
“Madalas ako secretions secretions will be
nahihirapan and/or inability lessened and
huminga ng to clear expectorated
maayos. Dati nga secretions that will
3- 4 lpm ung through the contribute to
oxygen ko para normal cough effective airway
makahinga ako ng mechanism clearance.
maayos. Pero may lead to
ngayon 2-3 pooling of Objectives:
nalang para secretions in 1. Teach the 1. Expectoration is The client was
masanay naman lower airways. 1. After the client how to the usual method able to expel
ung baga ko ng Pooling of nursing properly for collecting a the phlegm. The
mas mababang secretions intervention, expectorate sputum client also
oxygen.” leads to the client will phlegm. Also, specimen. The increased her
infection and be able to advise the patient is fluid intake that
Objective data: inadequate gas expel the client to instructed to helps in the
exchange. phlegm that increase fluid clear the nose decrease of the
• Patient has contributes to intake. and throat and viscosity of the
productive The client productive rinse the mouth phlegm.
cough with experiences cough. to decrease
blood-tinged episodes of contamination of
sputum in the coughing the sputum. If
morning and mechanisms for sputum is too
greenish clearing the thick to
sputum in the airway. A expectorate, it is
afternoon. patient who necessary to
• Breathing with coughs long decrease its
effort enough almost viscosity by
• With O2 invariably increasing water
 inhalation at produces. content through
bedside at 2-3 Violent adequate The client was
lpm via nasal coughing 2. Teach client hydration able to perform
canula. causes 2. After the the different (drinking water). the different
bronchial nursing types of types of
Measurement: spasm, intervention, breathing breathing and
Vital Signs: obstruction, the client will maneuvers 2. These coughing
and further be able to and assist the maneuvers will exercises and
Blood Pressure: irritation of the perform client in improve the this contributed
90/60 mmHG bronchi and coughing and performing productivity of to the
Body may result in breathing coughing and the cough. improvement of
Temperature: 36˚ syncope maneuvers breathing the productivity
C (fainting). A that will maneuvers. of cough.
Pulse Rate: 105 severe, alleviate the
bpm repeated, or aggravated
Respiratory Rate: uncontrolled condition.
30 cpm cough that is
non-productive 3. Instruct the The client
is exhausting client in the learned the
and potentially 3. After the following: ways to
Nursing harmful. nursing • Optimal 3. Directed alleviate the
Diagnosis: intervention, positioning coughing discomfort felt
Ineffective Maintaining a the client will (sitting techniques help through optimal
Airway patent airway be able to position or mobilize and proper
Clearance is vital to life. learn ways to high secretions from positioning,
related to Coughing is the alleviate the fowler’s smaller airways using of splints
excessive main difficulty felt position) to larger airways while coughing,
mucus as mechanism for in breathing • Use of because the using abdominal
manifested by clearing the that pillow or coughing is done muscle in
positive sputum airway. contributes in hand at varying times. coughing and
and abnormal However, the the splints The sitting increasing fluid
respiratory rate cough may be distressing when position and intake.
ineffective in cough. coughing splinting the
both normal • Use of abdomen
and disease abdominal promote more
states muscles effective
secondary to for forceful coughing by
factors such as cough. increasing
pain from • Increasing abdominal
surgical of fluid pressure and
incisions/ intake upward
trauma, diaphragmatic
respiratory movement. Relief
muscle fatigue, of dyspnea
or sometimes is
neuromuscular achieved by
weakness. placing the client
Other at rest with the
mechanisms head elevated
that exist in the (high fowler’s
lower position) and, in
bronchioles and severe cases, by
alveoli to administering The client was
maintain the 4. After the 4. Maintain oxygen. These able to conserve
airway include nursing planned rest positioning or gain energy
the mucociliary intervention, periods. promotes better from rest period
system, the client will Promote lung expansion and did not
macrophages, be able to energy- and improved air show respiratory
and the gain/conserve conservation exchange. distress.
lymphatics. energy and techniques to
Factors such as will not show the client.
anesthesia and respiratory 4. Fatigue is a
dehydration distress and contributing
can affect difficulties in factor to
function of the coughing will ineffective
mucociliary be lessened. coughing.
system.
Likewise, The client
conditions that 5. After the verbalized
cause nursing 5. Instruct understanding
increased intervention patient in the
production of the client will various importance of
secretions verbalize therapies, as therapeutic
(e.g., understandin appropriate: management for
pneumonia, g of • Assist with her condition.
bronchitis, and therapeutic procedures
chemical management • Assist with
irritants) can regimen for use of 5. Patient will
overtax these the respiratory understand the
mechanisms. betterment of devices rationale and
Ineffective her condition. and appropriate
airway treatments techniques to
clearance can . keep the airway
be an acute patent/
(e.g., secretions.
postoperative • Various
recovery) or therapies/
chronic (e.g., modalities
from may be
cerebrovascula required to
r accident acquire
[CVA] or spinal adequate
cord injury) airways,
problem. improve
Elderly respiratory
patients, who function and
have an gas
increased exchange.
incidence of
emphysema
and a higher
prevalence of
chronic cough
or sputum
production, are
at high risk.
Nursing Care
Process
Marquez, Earl Howard B.
FEU-IN
GROUP 109