Planning 3 NCPS
Planning 3 NCPS
Planning 3 NCPS
Nursing Care Plan
Assessment Nursing Diagnosis Planning Intervention Rationale Expected Outcome
Subjective Data: Ineffective airway After 2 hours of Independent: After 2 hours of proper
“Hindi ako masyadong makatulog clearance related to proper Nursing Nursing intervention
sa gabi dahil ubo ako ng ubo”, as bronchospasm as intervention the -Encourage the -To allow help maximize v the client was able to
verbalized by the client. evidenced by client will able patient to deep entilation. demonstrate behaviors
Cough to demonstrate coughing exercise to improve airway
Objective Data: behaviors to -The some degree of clearance
-Fatigue improve airway -Auscultate breath bronchospasm is present
clearance sounds. Note with obstructions in
-Productive Cough adventitious breath the airway.
sounds (wheezes,
-Presence of crackles on both crackles, rhonchi). -To identify the occurrence
lungs field upon auscultation of an infectious process.
-Observe the sign
-Restlessness and symptoms of -To promote wellness.
infections.
-Orthopnea
-Encourage -To promote better lung
Vital Signs: the patient to expansion and improved
BP – 160/90 mmHg adequate bed rest. gas exchange.
PR – 110 bpm -Position the patient -Ineffective cough may
in High-fowlers also signal
RR – 25 cpm position. impending respiratory failu
re.
T – 36.9 C
-Monitor the -Hydration helps decrease
O2 – 90 % cough and the viscosity of secretions,
sputum for color, facilitating expectoration.
consistency and am
ount. -This techniques will
prevent possible aspirations
-Increase fluid and prevent any untoward
intake to 3000 mL complications.
per day within
cardiac tolerance.
-To treat
for possible complication
-Demonstrate chest and infection.
physiotherapy, such
as bronchial tapping
when in cough,
proper postural
drainage.
Dependent:
-Administer
medication as
ordered.
Assessment Nursing Planning Intervention Rationale Expected Outcome
Diagnosis
Subjective Data: Impaired gas After 2 hours of Independent: After 2 hours of Proper
“Hindi ako masyadong makahinga”, exchange Proper Nursing -Encourage the patient deep -To promotes optimal chest Nursing Intervention the
as verbalized by the client. related to Intervention the breathing exercise. expansion and client was able to
altered oxygen client will able to drainage secretions. demonstrate improved
Objective Data: supply as demonstrate ventilation and
-Dyspnea evidenced by improved -Monitor the -Rapid, shallow breathing free from symptoms of
dyspnea ventilation and respirations, quality, and hypoventilation affect respiratory distress
-Abnormal breathing pattern free from symptoms rate, pattern depth and gas exchange by affecting
of respiratory breathing effort. CO2 levels.
-Abnormal breath sounds distress
-To reveals presence of
-Hypoxemia -Auscultate breath sounds pulmonary
and noting for congestion/collection of
-Hypoxia crackles, wheezing. secretion indicating need
for further intervention.
-For mobilization
-Maintain of secretions.
adequate fluid intake
-To decrease dyspnea and
-Encourage the patient to improve quality of life.
adequate sleep and rest.
-To maintain airway.
-Elevate the head of patient
or position the
patient appropriately.
-Monitor changes in the
level of consciousness and -Restlessness, agitation,
mental status. and anxiety are common
manifestations of hypoxia.
Dependent:
-Administer medication -To loosen secretions of
as ordered. the airways and improving
gas exchange.
-Administer supplemental -To prevents drying out
oxygen as ordered. the airways.
Assessment Diagnosi Planning Intervention Rationale Evaluation
s
Independent:
Subjective: Ineffective After 8 After 8 hours
breathing hours of Assess Manifestation of nursing
“Pakiramdam ko pattern nursing patient’s of respiratory intervention
related to
sobra akong pagod interventio respiratory distress the patient
Retained
at hirap ako sa pag n the status every include was able to
Secretions
hinga nung ilang as patient will 2 to 4 hours shortness of improved
linggo na ganito evidenced be able to as indicated breath, breathing
ang pakiramdam by improved and notify tachypnea, pattern and
ko” as verbalized Presence breathing any abnormal changes in maintain a
by the patient. of non- pattern and findings. mental status respiratory
productive maintain a and the use of rate within
Objective: cough respiratory accessory normal
rate within muscles. limits.
Fatigue normal Monitor vital For baseline
Shortness of limits. signs data.
breath Auscultate Decreased
Cough breath breath sounds,
Restlessnes sounds every crackles,
s 2 to 4 hours wheezes, and
Disturbed as indicated. rhonchi can be
sleep due to observed and
coughing must be
reported
Vital Signs: promptly for
BP: 164/92 immediatemen
mmHg t treatment.
PR: 110
bpm Instruct how Promotes
RR: 25cpm to splint the physiological
Temp: chest wall ease of
36.9°C with a pillow maximal
O2 sat: 93% for comfort inspiration.
during
drop to 90%
coughing and
on the elevation of
following head over the
excertion body as
Height: 5ft. appropriate. Aid in
2 inches Provide relieving the
Weight: 180 respiratory patient from
lbs. support. dyspnea.
Oxygen