NURSING CARE PLAN

General Objective: To promote optimal activity: exercise, rest, sleep

Assessment Nursing Rationale Specific Nursing Rationale Evaluation

Diagnosis Objectives Intervention

Subjective Activity Coughing is Within 4 hours Independent After 4 hours

Cues: intolerance the body's of nursing -Evaluate -Establishes of nursing
Ga ubo man related to way of Interventions patients patients interventions,
ko gyapon. Ga exhaustion removing the patient will Respons e to capabilities the patient was
untat2x akon activity. or needs and
associated foreign be able to able to
tulog sa
with material or demonstrate a facilitates demonstrate a
Gabi. As
Interruption in mucous from measurable choice of measurable
verbalized by
the patient. usual sleep the lungs increase in interventions. increase in
pattern and throat. tolerance in tolerance in
secondary to The two activity with -Reduces activity with
Objective Cough. general decrease RR of -Provide a quiet stress and decrease RR of
Cues: classification 16-20 cpm. environment and excess 20 cpm from 24
*Productive s of cough limit visitors stimulation, cpm.
cough noted are during acute promoting
with whitish phase. rest.
productive
phlegm.
coughs
*tired and
(producing -Elevate head -These
sleepy eyes
phlegm or and measures
noted.
*Capillary refill mucous from encourage promotes
of 2 seconds. the lungs) frequent maximal
Vital signs: and position changes, inspiration,
*Temp 360C nonproducti deep breathing enhance
(36.5-37.50C) ve coughs and expectoration
*CR 82 bpm (dry and not effective of
(60-100 bpm) producing coughing. secretions to
*RR 24 cpm improve
any mucous
(12-20 cpm)
or phlegm). ventilation.
*BP 110/80
mmhg Coughs are
(120/80 also divided -Facilitates
mmhg) into acute -Encourage healing
(less than 3 adequate rest process and
weeks' balanced with enhances
duration) moderate natural
and chronic activity. resistance.
(more than Promote
three weeks' adequate
Duration). nutritional - Fluids
Acute cough intake. especially
is most often warm liquids
caused by -Encourage aid in
the common adequate fluids mobilization
viral upper to and
respiratory at least 3000 ml expectoration
tract per day and of secretions.
Infection. offer warm,
Patient H.N., rather than cold
was not able fluids.
to have a
good sleep Collaborative -Aids in
at night -Administer reduction of
because of medications as bronchospasm
cough prescribe: and
disturbances Fluimucil mobilization
in time of (mucolytic) of secretions.
sleep 600mg BID 1 tab, Exerts
resulting to P.O. mucolytic
sleepy and action through
tired eyes as its free
seen in sulfhydryl
patient. group which
opens up the
disulfide bonds
in the
mucoproteins
thus lowering
mucous
viscosity.