Nursing Care Plans

NURSING CARE PLANS CUES / PROBLEM Subjective cues:

NURSING DIAGNOSIS

“Nahihirapan ako huminga” as verbalized by the patient.

OBJECTIVE

After 3 days of nursing interventions, the

Ineffective breathing pattern

patient will:

Objective cues: Tachypnea

related to inhaled irritants

•

Cyanosis & Cough

evidenced by regular respiratory rate

Nasal flaring & Wheezing

16 – 20 breaths per minute.

Fatigue & weak looking Excessive sweating

•

Use of accessory muscle. V/S taken as follows: RESPIRATORY RATE : 30 Breaths per minute TEMPERATURE : 37.5 degree Celsius PULSE: 60 beats per minute BLOOD PRESSURE: 110 / 80 mmHg

Report comforts and feeling rested each day.

Pale and dry lips Abnormal breath sounds.

Maintain optimal breathing pattern as

•

Demonstrate behaviors to improve airway clearance.

PLANNING

NURSING INTERVENTION

RATIONALE

ASSESSMENTS: •

•

Assess respiratory rate and depths;

•

Elevate head of the bed, have patient

•

This position allows for adequate

monitor breathing pattern

lean on overbed table or sit on edge of

diaphragm excursion and lung

Monitor oxygen saturation by pulse

the bed.

expansion. Elevation of the bed

oximetry as ordred by the physician.

facilitates respiratory function by use

•

Assess level of anxiety.

of gravity.

•

Assess for fatigue and the patient’s

•

•

Encourage slow deep breathing.

•

Pursed – lip breathing during

perception of how tired he feels.

Instruct or assist with abdominal or

exhalation facilitates expiratory airflow

Plan activity and rest to maximize the

pursed lip breathing exercises.

by helping to keep the bronchioles open. Provides patient with some

patient’s energy.

means to cope with or control dyspnea

ACTIVITIES : Teach patient about : 1. Pursed lip breathing

•

and reduce air tapping.

Auscultate breath sounds at least •

To detect decrease or adventitious

2. Abdominal breathing

every 4 hours. Note adventitious

3. Performing relaxation technique

breath sounds like wheezes, crackles

breath sounds. Some degree of

4. Taking prescribed medications

and rhonchi.

bronchospasm is present with obstructions in airway and may or may

not be manifested in adventitious breath sounds. •

Help patients with activity daily living as needed.

•

•

To conserve energy and avoid overexertion and fatigue.

Administer oxygen as ordered. •

Supplemental oxygen helps reduce hypoxemia and relieve respiratory

•

Administer medication as ordered

distress.

especially bronchodilators. •

To relax airway smooth muscles, work quickly to open air passage, make it easier to breath and decrease

•

THERAPEUTIC MANAGEMENT: •

Increased fluid intake to 3000 ml/ day.

bronchoconstriction; To reduce the

Provide warm or tepid liquids.

viscosity of secretions.

•

Hydration helps decrease the viscosity

Anticipate symptoms progression from

of secretions, facilitating

acute phase to late phase periods.

expectoration. Using warm liquids may

decrease bronchospasm.

•

Reassure patient’s maintenance medications at the times when increased symptoms are anticipated.

•

So that anti-inflammatory corticosteroids, which act slowly, may

•

Include the family members in health

be started before urgent care is

teachings with the patient regarding

needed.

administration of maintenance medications.

•

To avoids morbidity and decreases the likelihood that urgent care will be

•

Keep environmental pollution to a

needed.

minimum like dust, smoke and feather pillows, according to individual situation.

•

To decrease the anxiety of the patient and his family; cooperation of the family in providing care to the patient

•

Assist with measures to improve

with the health care team fosters fast

effectiveness of cough effort.

recovery. •

Precipitators of allergic type of respiratory reactions that can trigger or exacerbate onset of acute episode.

•

Coughing is most effective in an upright position after chest percussion.

NURSING IMPLEMENTATION

EVALUATION

After 3 days of nursing interventions, •

Keep head of the bed elevated DONE

•

Encourage slow deep breathing.

RESPIRATORY RATE – 18 Breaths per

Instruct the patient to use pursed – lip

minute

breathing for exhalation DONE

TEMPERATURE – 37 degree celcius

Auscultate breath sounds at least

PULSE RATE – 90 beats per minute

every 4 hours DONE

BLOOD PRESSURE – 120 / 80 mmHg

•

•

•

Patient’s vital signs stable:

Help patients with activity daily living

•

Patients performs breathing execises.

as needed DONE

•

When patient carries out activity daily

•

Administer oxygen as ordered DONE

living, breathing patterns remains

•

Administer medication as ordered

normal.

DONE

•

Feeling comfortable when breathing as verbalized by the patient.

•

Patient report feeling rested each day.

•

Patient was able to demonstrate behaviors to improve airway

clearance.