Milambiling, ma.imogen L.

Bsn 123

NURSING CARE PLAN

Nursing Analysis Goals and Interventions Rationale Evaluation

Diagnosis Objectives

Ineffective Inability to After 30 minutes After 30

Airway clear of nursing minutes of
Clearance secretions or
Intervention the nursing
related to obstructions
from client will be able Intervention
retained
secretions in respiratory to expectorate/ the client can
the bronchi as tract to clear secretions able to
manifested by maintain a readily. expectorate/
ineffective clear airway clear
cough Objectives: secretions
Monitor respirations Indicative of readily.
• the patient and breath sounds, respiratory
S: “Hindi ako
will be able noting rate and distress and/or Met___
makahinga ng
sounds accumulation of
maayos. Para ba to maintain
secretions.
gang may adequate, Unmet___
nakabara sa patent
lalamunan ko.” airway
Evaluate client’s To determine
O:
cough/gag reflex ability to protect
>RR: 32cpm
and swallowing own airway
>PR: 76bpm
>BP: 110/60 ability
mmHg
> tachypnea
To clear/maintain
> use of Assist with open airway
accessory muscle procedures
to breathe

To maximize effort
Encourage deep-
breathing and
coughing exercises;
splint chest. To improve cough
when pain is
inhibiting effort
Administer
analgesics
Hydration can help
liquefy viscous
secretion and
improve secretion
Increase fluid intake clearance
to at least
2000ml/day within
cardiac intolerance