NURSING CARE PLAN

Problem: Cough
Nursing Diagnosis: Ineffective airway clearance related to increased mucus production secondary to asthma
Taxonomy: Activity-Exercise Pattern
Cause Analysis: Mucosal edema due to increased vascular permeability and increased secretion. (Medical-Surgical Nursing by Brunner and Suddarth 4th Edition p 375)

CUES OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

Short Term Objectives Independent

After 8 hours of duty and - Assessed/monitored vital signs - Changes in vital signs may Patient was able to
appropriate nursing care indicate acute pain or discomfort verbalize, “naa man
interventions, the patient - Provided additional comfort - Improves circulation, reduces gihapon ko’y ubo pero
Subjective Cues will be able to demonstrate measures like backrub, heat/cold muscle tension and anxiety maarangan basta nay
behavior to achieve airway application associated with pain. Enhances well- tambal.”
“Ubhon ko panalagsa,” as clearance and will have an being
verbalized by patient improved condition - Assisted patient with deep - Deep breathing facilitates
breathing exercises maximum expansion of the
Long Term Objectives lungs/smaller airways
Objective Cues - Observed characteristic of cough eg - Cough can be persistent but
- Patient has After 3 days of duty and persistent, moist, etc. Assisted with ineffective especially if the patient is
occasional non- appropriate nursing measures to improve effectiveness of elderly
productive cough interventions the patient will cough effort
- RR 20-25 cpm be able to appear relaxed, - Encouraged intake of fluid of 3000 - Fluids aid in mobilization and
- (+) tactile fremitus verbalize improvement in ml per day expectoration of secretions
- (+) rales right side airway clearance. - Encouraged/assisted with - Provides patient with some
- decreased sound on abdominal or pursed lip breathing means to cope with/control dyspnea
left chest exercises and reduce air trapping
- pt appears weak - Prevents development of further
- patient looks to be - Encouraged to avoid allergenic attacks
lacking sleep substances (eg dust, chemicals,
smoke, etc)

Dependent
- Bronchodilator; relaxes bronchial,
- Administer medications as uterine, an vascular smooth muscles
prescribed (Ventolin nebule) by stimulating beta 2 receptors

Reference: Nursing Care Plans by Doenges, Fundamentals of Nursing by Kozier 5th edition
STUDENT NURSES’ COMMUNTY

NURSING CARE PLAN - Bronchitis ASSESSMENT DIAGNOSIS OBJECTIVE INTERVENTION RATIONALE EVALUATION

Subjective: “
Nahihirapan ako huminga”
(Im having difficulty
breathing
) as verbalized by the
patient.

Objective:
•
Presence of rhonchi.
•
Ineffective cough.
•
V/S taken as follows: T: 37.2 P: 79 R: 24 BP: 110/80

Ineffective airway clearance related to excessive, thickened mucous secretions.

Short term:
After 8 hours of nursing interventions the patient will:
•
Demonstrate improved ventilation and adequate oxygen.

•
Arterial blood gases (ABGs) within normal range.
•
No signs of respiratory distress.
Long term:
After months of nursing interventions, the patient:
•
Ventilation or oxygenation is adequate to meet self care needs.
Independent:
•
Assess respiratory rate, depth. Note use of accessory muscles, pursed lip breathing, Inability to speak.
•
Elevate head of the bed, assist patient assume position to ease work of breathing. Encourage deep slow or pursed lip breathing as individually tolerated or indicated.
•
Routinely monitor skin and mucous membrane color.
•
Encourage expectoration of sputum; suction when indicated.

•
Useful in evaluating the degree or respiratory distress and chronicity of the disease process.
•
Oxygen delivery may be improved by upright position and breathing exercises to decrease airway collapse, dyspnea and work of breathing.
•
Cyanosis may be peripheral in nail beds or central in lips or earlobes. Duskiness and central cyanosis indicate advanced hypoxemia.
•
Thick, tenacious, copious secretions are major source if ineffective airways. Deep suctioning may be required when cough is ineffective for expectoration of secretions.

•
Patient display improved ventilation and adequate oxygenation of tissues and Arterial blood gases (ABGs) within normal range and free from symptoms of respiratory distress.

STUDENT NURSES’ COMMUNTY

•
Evaluate level of activity tolerance. Provide calm and quiet environment.
•
Evaluate sleep patterns, note report of difficulties and whether patient feels well rested.
♦
Monitor vital signs and cardiac rhythm.
Collaborative:

•
Administer supplemental oxygen as indicated by ABG results and patients tolerance.

•
During severe or acute respiratory distress, patient may be totally unable to perform basic self care activities because of hypoxemia and dyspnea.
•
 Multiple external stimuli and presence of dyspnea may prevent relaxation and inhibit sleep.
•
Tachycardia, dysrhythmias, and changes in blood pressure can reflect effect of systemic hypoxemia on cardiac function.
•
May correct or prevent worsening of hypoxia.