NURSING CARE PLANS

CUES / PROBLEM NURSING DIAGNOSIS OBJECTIVE

Subjective cues:

“Nahihirapan ako huminga” as verbalized by the After 3 days of nursing interventions, the
patient.
Ineffective breathing pattern patient will:
Objective cues:

Tachypnea related to inhaled irritants

• Maintain optimal breathing pattern as
Cyanosis & Cough
evidenced by regular respiratory rate
Nasal flaring & Wheezing
16 – 20 breaths per minute.
Fatigue & weak looking
• Report comforts and feeling rested
Excessive sweating

Pale and dry lips each day.

Abnormal breath sounds. • Demonstrate behaviors to improve

Use of accessory muscle. airway clearance.

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

 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

pursed lip breathing exercises. by helping to keep the bronchioles

• Plan activity and rest to maximize the
open. Provides patient with some
patient’s energy.
means to cope with or control dyspnea
ACTIVITIES : Teach patient about :
• Auscultate breath sounds at least and reduce air tapping.
1. Pursed lip breathing
every 4 hours. Note adventitious • To detect decrease or adventitious
2. Abdominal breathing
breath sounds like wheezes, crackles breath sounds. Some degree of
3. Performing relaxation technique
and rhonchi. bronchospasm is present with
4. Taking prescribed medications
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

• Administer oxygen as ordered. overexertion and fatigue.

• 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

• Increased fluid intake to 3000 ml/ day. bronchoconstriction; To reduce the

Provide warm or tepid liquids. viscosity of secretions.

THERAPEUTIC MANAGEMENT: • 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 • Patient’s vital signs stable:

• 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

• 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.