St.

Anthony’s College
San Jose, Antique
Nursing Department
NAME: L.C.G ADDRESS: Catungan IV, Sibalom, Antique
AGE: 49 BIRTHDAY: July 06, 1970
CC: DOB RELIGION: Roman Catholic
NURSING CARE PLAN
CUES NURSING RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE: Ineffective airway Inability to clear GENERAL: After 8 INDEPENDENT:
“Nabudlayan ako mag clearance related secretions or hours of Nursing  Monitor  Indicative of Goals partially met as
ginhawa” as verbalize by to obstructed obstructions from the intervention, the respirations and respiratory evidenced by the patients
the patient. airway respiratory tract to patient will be able to breath sounds, distress able to expectorate
maintain a clear maintain airway noting rate and and/or secretions.
airway. patency. sounds. accumulation
of secretions.

 Assist the client  For diaphragm

to semi fowlers expansion and
OBJECTIVE: position promote
 Diminished inhalation
breath sounds
crackle at left.  Hydration can
 Increase fluid help prevent
 Excessive sputum intake to at least the
2,000 mL/day accumulation
 Alterations in within cardiac of viscous
respiratory rate tolerance. secretions and
or pattern improve
secretion
 Difficulty clearance.
verbalizing

 Restlessness
 Cyanosis  Auscultate  To ascertain
breath sounds current status
and assess air and note
movement. effects of
treatment in
clearing
airways.

 Administer  To improve
oxygen breathing
inhalation pattern.

 Administer  To relax
bronchodilator smooth
such as respiratory
Ipratropium musculature,
Bromide reduce airway
(salbutamol) edema.