VI.

Nursing Care Plan

Assessment Nursing Diagnosis Planning Implementation Evaluation

Subjective: Ineffective airway clearance After 30 minutes of nursing ● Assess home environment Goal Met
related to nasal congestion as intervention the patient will be for factors that exacerbate
“Hindi ako makahinga ng maayos evidence by runny nose and able to display patent airway airway clearance
dahil barado ilong ko sa sipon” as watery, red eyes problems
verbalized by the patient
● Teach adaptive breathing
Objective: techniques.

● Runny nose ● Note presence of sputum;

● Watery, red eyes evaluate its quality, color,
● Use of accessory muscles amount, odor, and
● Adventitious breath consistency.
sounds
● Difficulty verbalizing ● Assist patient to a sitting
● Changes in respiratory position with head slightly
rate and rhythm flexed,shoulders relaxed,
and knees flexed

● Encourage increased fluid

intake of up to 3000
ml/day within cardiac or
renal reserve.

● Monitor rate, rhythm,

depth, and effort of
respirations

● Encourage client to use

incentive spirometer
● Assist with clearing
secretions from pharynx
by offering tissues and
 gentle suction of the
oropharynx if necessary
● Provide oral care every 4
hours.
● Administer oxygen as
ordered.
● Document results of
coughing and suctioning,
particularly client
tolerance and secretion
characteristics such as
color, odor, and volume.
Assessment Nursing Diagnosis Planning Implementation Evaluation
Subjective: Pain related to excessive dry After an hour of nursing ● Assist client to elevate Goal met
cough as evidenced by pain scale intervention, pain scale will be head
“Hindi ako makahinga ng of 8 and facial grimace from 8 to 3. ● Encourage frequent
maayos dahil sa kakaubo mag position changes and
damag” as verbalized by the effective coughing
patient ● Encourage to increased
fluid intake
Pain scale of 8 ● Encourage to take warm
Facial grimace fluids instead of cold
● Keep the environment
Objective: allergy free and quiet
● Assist to take cough
● Use of accessory muscles medicine prescribed by
● Adventitious breath doctor
sounds ● Encourage adequate rest
● Difficulty verbalizing balanced
● Dyspnea
● Fatigue
● Dry cough
● Wheezing sound
● Changes in respiratory
rate and rhythm