NURSING CARE PLAN

Diagnosis Need Desired Interventions Rationale Evaluation Intervention Rationale

Outcome Statement Modification
1. Ineffective airway After 8 hours
clearance related to of nursing
plueric chest pain, P intervention,
positioning, fatigue, H she will be
and thick secretions Y able to:
as manifested by S
cough, tenacious I General:
sputum, crackles/ O  Maintain
wheezes and L patent airway.
dyspnea. O Independent
G Specific: 1. Establish 1. This would Goal met. Continue Bronchop
S/O cues: I  Expectorat rapport with the help in building The patient nursing neumonia
-with pleuritic pain C e secretions patient and trust of the was able to intervention cannot be
-with headache readily. significant patient to the maintain s. treated for
-dyspnea N others. student nurse. patent 8 hours. It
-tachypnea E Rapport will help airway by needs a
-chills E  Establish the student expectoratin longer
-low grade fever D clear breath obtain accurate g time so
-rapid shallow sounds. data from the secretions. the
breathing patient and the The patient interventio
-Cough with significant other. also ns should
greenish or yellow Provides manifest be
mucu-appears therapeutic and continued
anxious communication established to
-with sputum between the clear breath promote
production student nurse sounds comfort.
-Weakness noted and the patient upon For
-flushed cheeks as well as the auscultation continuity
-use of accessory significant other. . of care
muscles and
2. This will serve
-crackles/ wheezing facilitate
as the baseline
-consolidation 2. Monitor and patient in
data for the shift.
-bronchial breath record vital recovery.
It would help in
sounds signs.
determining the
-chest expansion
current status of
may be diminished /
the patient and
unequal on
determine
inspiration
response to the
VS:
-Temperature is . therapy.
above normal value
because of increase
in pyrogens- 37.9⁰C 3. IVF 3. To provide
-Pulse is rapid, regulation and accurate amount
weak- 90 bpm monitoring of IVF to the
-RR- 29cpm patient
-BP- may be . preventing fluid
hypotensive – volume deficit/
80/60mmHg overload.

Background: 4. Evaluate 4. To determine

Inability to clear cough reflex the ability in
secretions or and swallowing protecting
obstructions from ability. airway.
the respiratory tract
to maintain a clear 5. Promote 5. To reduce
airway. rest. oxygen demands
Pneumonia is of tissues and
caused by a prevent fatigue..
bacterial/ viral
infection that results 6. Monitor 6. This would
in an inflammatory respiration and help in
process in the lungs. breath sounds. determining
It is an infectious respiratory
process that is distress and
spread by droplets accumulation of
or by contact. secretions.
Bronchopneumonia
is a term used to 7. Provide an 7. To promote an
describe pneumonia allergen free environment
that is distributed in environment. conducive to the
a patchy fashion, condition of the
having originated in patient and
one or more reduce the risk of
localized areas worsening of the
within the bronchi condition.
extending to the 8. Assist
8.To take
adjacent patient in semi-
advantage of the
surrounding lung fowler’s
gravity
parenchyma. position.
decreasing
 pressure on the
diaphragm and
enhancing
drainage of
secretions. To
maximize lung
expansion.
9. Provide
adequate fluids
9. Hydration can
and encourage
help liquefy
use of warm
viscous
liquids.
secretions and
improve
secretion
clearance. Warm
liquids aids to
lessen viscosity
of secretions.
10. Encourage
to expel 10. To remove
secretions the secretions
 and decrease
secretions from
the respiratory
11. Encourage tract.
to splint chest
11. To minimize
when
chest pain when
coughing.
coughing.
and deep
breathing
exercise.

12. Provide
12. To determine
information
the color of
about the
secretions thus
necessity of
aid in
expectorating
determining the
secretions
type infection.
versus
swallowing it.

13. Assist and

facilitate oral 13. To remove
hygiene unpalatable taste
measures. of mucous
secretions from
mouth.
14. Provide
humidification 14. To prevent
of inhaled air. dryness of
mucous
membranes.
15. Facilitate in
suctioning 15.To maintain
mucous patent airway
and facilitate
removal of
sputum and
mucous plugs.
Collaboration/
Dependent
1. Monitor
sputum, chest 1. To determine
x-ray. changes and
improvement of
the condition and
determine
progression of
the disease
process.
2. Administer
medications 2. To follow the
ordered by the therapeutic
physician. regimen and aid
patient in
recovery. To
promote
expectoration.
3. Administer
oxygen therapy 3. To maintain
as ordered. optimal oxygen
level and
increase comfort.
4. Monitor
arterial blood 4. To assess
gasses as oxygenation
ordered. status.

5. Consult
respiratory 5. To aid in
therapist for improving the
chest patient’s
physiotherapy condition and to
and nebulizer provide comfort.
treatments.

6. Assist with
bronchoscopy 6. To assist
and patient in
thoracentesis recovery and
as needed. promote comfort.