Nursing Care Plan

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ASSESSMENT | DIAGNOSIS | RATIONALE | PLANNING | INTERVENTION | RATIONALE | EVALUATION | Subjective:◈ “Nahihirapanakong humingadahil sa kakauboko,” as verbalized by the patient.Objective:◈ pale inappearance◈ dyspnea◈ (+) use ofaccessory muscleswhen breathing◈ (+) productivecough◈ RR=24 bpm | IneffectiveAirway Clearance related to secretions inthe bronchi | Irritant(inhalation) ↓inflammatoryresponse ↓increase productionof secretions ↓airway constriction ↓dyspnea | After 4 hours ofnursingintervention, airwaypatency will bemaintained,secretions will bereadilyexpectorated andthere will be signsof reduction incongestion. | Independent:◈ Vital signsmonitored andrecorded.◈ Assist in semi-fowler’s position.◈ Encouraged deepbreathing exercise.Dependent:◈ Administeredprescribedmedications.◈ Providedsupplementalhumidification viause of nebulizer. | * This is forbaselinecomparison.◈ Proper positioninghelps in drainingsecretions.◈ This will promoteproper lungexpansion.◈ Prescribed medssuch asbronchodilatorshelps in aidingeffective airwayclearance.◈ Nebulizationhelps in liquefyingsecretions for betterand fasterexpectorating thesecretions. | After 4 hours ofnursingintervention, thegoal is met throughmaintenance ofairway patency andreduction incongestion. | ASSESSMENT | DIAGNOSIS | RATIONALE | PLANNING | INTERVENTION | RATIONALE | EVALUATION | SUBJECTIVE:“Natatakot akong magpaopera!” as verbalized by the patient.OBJECTIVE: * Restlessness * Voice quivering * Hand tremors * Facial flushing * apprehension | Anxiety related to perceived threat to death as manifested by increased tension. | The emotional response of the patient during illness is of extreme importance. The mind-body-spirit connection is well established; it is known, for example, that when a physiological response occurs, there is a corresponding psychological

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