NURSING CARE PLAN

NURSING DIAGNOSIS # 1 : Ineffective airway clearance related to airway

obstruction due to inflammatory response to allergens as evidenced by continuous
coughing


GOAL: regain normal patency of airway
EXPECTED OUTCOME:
At the end oI the 8 hours oI nursing care management, the patient will not maniIest
signs oI respiratory distress:
(-) cyanosis
(-) grunting
(-)nasal Ilaring
(-)use oI accessory muscles
() unlabored breathing
INTERVENTIONS EVALUATION
1. Take vital signs
For baseline data



2. Monitored the rising and Ialling oI
respiratory rate.



3. Assess breath sounds
%o assess presence of abnormality
in the patency of the airway


4. Position in high back rest
%o promote lung expansion


5. Frequent change in position
For mobili:ation of secretions


6. Increased Iluid intake
%o loosen up secretions


7. Provided quiet and comIortable
environment
For maximum comfort


8. Provided adequate rest periods
For comfort and rehabilitation
9/2/11/1600H
O PR: 98
O RR: 24
O 36.0 C

Respiratory rate rose Irom 24 cpm
(1600H) to 27cpm (2000H)



No abnormal breath sounds present
Clear breath sounds



Patient is positions in high Iowler`s
position


Encouraged the patient Ior ambulation



Provided health teachings on increasing
oral Iluid intake to loosen secretions.
Patient`s Iather understood the health
teaching
Quiet an comIortable environment is
provided



The patient was able to rest























































9. Nebulize the patient
%o loosen up secretion, aids in
coughing out of airway obstructions
and mucus

10.eep environment allergen-Iree

Nebulization done by staII nurse on duty




Environment was clean and allergen Iree
NURSING CARE PLAN
NURSING DIAGNOSIS # 2: ineffective breathing pattern related to inflammatory
process as evidenced by abnormal breath sounds (wheezes) on the left upper, left
lower, right upper and right middle lobes.
GOAL: to regain patency oI airway and keep respiratory rate within normal range and
no signs and symptoms oI respiratory distress
EXPECTED OUTCOME:
At the end oI the 8 hours oI nursing care management, the patient will not maniIest
signs oI respiratory distress:
(-) cyanosis
(-) grunting
(-)nasal Ilaring
(-)use oI accessory muscles
() unlabored breathing
INTERVENTIONS EVALUATION
1. Take vital signs
For baseline data



2. Monitored the rising and Ialling oI
respiratory rate.



3. Assess breath sounds
%o assess presence of abnormality
in the patency of the airway


4. Position in high back rest
%o promote lung expansion


5. Frequent change in position
For mobili:ation of secretions


6. Increased Iluid intake
%o loosen up secretions


7. Provided quiet and comIortable
environment
For maximum comfort


8. Provided adequate rest periods
For comfort and rehabilitation
9/2/11/1600H
O PR: 98
O RR: 24
O 36.0 C

Respiratory rate rose Irom 24 cpm
(1600H) to 27cpm (2000H)



No abnormal breath sounds present
Clear breath sounds



Patient is positions in high Iowler`s
position


Encouraged the patient Ior ambulation



Provided health teachings on increasing
oral Iluid intake to loosen secretions.
Patient`s Iather understood the health
teaching
Quiet an comIortable environment is
provided



The patient was able to rest
























































9. Nebulize the patient
%o loosen up secretion, aids in
coughing out of airway obstructions
and mucus

Nebulization done by staII nurse on duty
NURSING CARE PLAN























































NURSING DIAGNOSIS # 3: Hypethermia related to allergic reaction as evidenced
by temperature of 37.6 C upon admission
GOAL: to stabilize temperature to within normal range
EXPECTED OUTCOME:
At the end oI the 8 hours oI nursing care management, the patient will maniIest signs
oI hyperthermia and regain temperature within normal range:
(-) cyanosis
() skin turgor
() rapid capillary reIill
(-) Iever


INTERVENTIONS EVALUATION
1. Take vital signs
For baseline data



2. Monitor temperature


3. Position in high back rest
%o promote lung expansion


4. Frequent change in position
For mobili:ation of secretions


5. Provide quiet and comIortable
environment
For maximum comfort


6. Provide adequate rest periods
For comfort and rehabilitation

7. Provide tepid sponge bath
%o decrease temp




9/2/11/1600H
O PR: 98
O RR: 24
O 36.0 C

Latest temperature (2000H): 35.8 C


Patient is positions in high Iowler`s
position


Encouraged the patient Ior ambulation



Quiet an comIortable environment is
provided



The patient was able to rest


The patient was given spongebath

NURSING CARE PLAN






















































NURSING DIAGNOSIS # 4: Anxiety related to hospitalization as evidenced by
attempt of pulling out of heplock and signs of guarding when vital signs were taken
GOAL: to patient to gain conIidence
EXPECTED OUTCOME:
At the end oI the 8 hours oI nursing care management, the patient will participate in
activities:
(-) guarding
() good activity
(-) anxiety
() conIidence


INTERVENTIONS EVALUATION
1. Take vital signs
For baseline data



2. Position in high back rest
%o promote lung expansion


3. Frequent change in position
For mobili:ation of secretions and
increase in activity

4. Provided quiet and comIortable
environment
For maximum comfort


5. Provided adequate rest periods
For comfort and rehabilitation

6. Encouraged verbalization oI
Ieelings and concerns

7. Establish trust to the patient





9/2/11/1600H
O PR: 98
O RR: 24
O 36.0 C

Patient is positions in high Iowler`s
position


Encouraged the patient Ior ambulation



Quiet an comIortable environment is
provided



The patient was able to rest


Patient verbalized concerns


Nurses provided the patient what he
needed