B.

NURSING CARE PLAN

Assessment

Nursing
Diagnosis

Subjective

Ineffective

Data:

Scientific
Explanation
Bronchiectasis

Planning

Implementatio
n

Scientific
Rationale

Evaluation

After 8 hours of

Goal Met

airway clearance is a chronic

nursing

After 8 hours of

related to

irreversible

intervention, the

nursing

retained

dilation of the

patient will be

intervention, the

Objective Data: secretions as

bronchi and

able to:

client now able

- RR of 32 bpm

evidenced by

bronchioles.

- Difficulty of

productive and

Such dilation of

1. Expectorate

* Encourage

- Hydration can

1. Expectorate

Breathing

ineffective

the bronchial

secretions.

increase fluid

help liquefy

secretions as

- Shortness of

cough.

walls causes

intake at least 2

viscous

evidenced by

Breathing

disruption of

L/day.

secretions thus

whitish scanty

- Use of

normal air

improving

phlegm.

Accessory

pressure in the

secretion

Muscles

bronchial tubes,

clearance.

- Productive

causing airflow

Cough

obstruction and

* Administer

- To metabolize

airway as

- Crackles on

pooling of

expectorant/

secretions.

evidenced by

both lung fields

sputum inside

bronchodilators

decreased

the dilated areas

as ordered.

Respiratory Rate

instead of being

to:

2. Maintain/
achieve patent

(20 bpm).

pushed upwards.
Unable to

2. Maintain/

expectorate
secretions this

- To maximize

3. Educate

Achieve a patent deep-breathing

effort of

patient and

airway.

exhalation.

relative on how

now leads to

* Encourage
and coughing
exercises.

to improve

ineffective

current health as

airway

* Elevate head

- To take

evidenced by

clearance.

of bed/change

advantage of

demonstration of

position every

gravity,

behavior of

two hours.

decreasing

following health

pressure in the

teachings.

diaphragm.
* Obtain and

- To determine if

refer specimen

therapy is

to laboratory as

effective.

ordered.

3. Educate

* Provide

- To report

patient and

information

changes in color

relative on how

about necessity

and amount to

to improve

of raising and

determine if

current health.

expectorating

medical

secretion vs.

intervention

swallowing

may be needed.

them.

Assessment

Nursing
Diagnosis

Scientific
Explanation

Planning

Implementatio
n

Scientific
Rationale

Evaluation

Subjective

Ineffective

Repeated

After 4 hours of

Goal Met

Data:

breathing

episodes of

nursing

After 4 hours of

pattern related to pulmonary

intervention, the

nursing

respiratory

infection

patient will be

intervention, the

Objective Data: muscle fatigue

stressed great

able to:

patient now able

- RR of 32 bpm

as evidenced by

risk to the

- Difficulty of

use of accessory

respiratory

1. Relief from

* Auscultate

- To evaluate

1. Relief from

Breathing

muscles and an

muscles which

difficulty of

breath sounds.

presence/

difficulty of

- Use of

RR od 26 bpm.

leads to this

breathing.

character of

breathing as

breath sounds/

evidenced by

Accessory

bronchiectasis.

to:

Muscles

With those

secretions.

decreased

- Shortness of

frequent

breathing

infections,

* Administer

muscles that are

oxygen at lowest management of

necessary for

concentration

underlying

2. Know and

normal

indicated.

pulmonary

perform ways to

condition.

maintain

Respiratory rate

respiratory

- For

functions are

(20bpm).

comfort as

weekend.

* Elevate head

- To promote

evidenced by

Retained

of the bed or

physiological/

deep breathing

secretions also

have patient sit

psychological

exercise,

add to the

up in bed as

ease of

maintain good

condition which

appropriate.

maximum

posture, and

inspiration.

effective use of

obstructs airway
leading to

accessory

ineffective

muscle.

breathing

2. Know and

* Assist patient

- To promote

pattern.

perform ways to

in the use of

relief from

maintain

relaxation

difficulty of

comfort.

technique such

breathing.

as deep
breathing

exercises.
* Stress the

- To maximize

importance of

respiratory

good posture

effort.

and effective use

of accessory
muscle.
* Maintain calm

- To limit level

attitude while

of anxiety.

dealing with
patient and
significant
others.