VII.
NURSING CARE PLAN
Name: Mr. JRB
Age/ gender: 54 years old/ Male
Nursing Diagnosis
Ineffective airway clearance
Ineffective breathing pattern
Thermoregulation, ineffective
Unit: Emergency Room Admitting Dx: CAP mod. Risk
CC: Fever for 4 days Attending Physician: Dr. Untalan
Prioritization SIGNIFICANCE
1 In assessment (ABC), airway should
always be prioritized
2 Breathing should also be assess to know
if the client has access to airway, or need
mechanical support
3 Thermoregulation is important sisce this
may lead to fluid volume deficit if not
given proper attention.
PLANNING INTERVENIONS RATIONALE EVALUATION
 VII. NURSING CARE PLAN

NURSING
ASSESSMENT
DIAGNOSIS

Subjective cue: Ineffective airway After 1-2 hours of  Monitor  This will After 2hrs of
“Medyo nahihirapan clearance related Nursing respirations and indicate the nursing
ako huminga pero to productive intervention: breath sounds respiratory intervention:
konti lang,” as cough as evidence noting rate and distress and
verbalized by the by cough. Patient will be able sounds. accumulations Patient was able
client. to expectorate of breath to expectorate
secretions and sounds. secretions and
Objective cues: maintain patent maintained airway
airway clearance.  Evaluate client’s  This will clearance as
 RR: 28 cpm cough reflex determine the evidenced by:
and swallowing patient’s
 Use of accessory ability ability to  RR: 19 cpm,
muscles for protect  Calmness
breathing airway. and,
 not using
 Restlessness  Positioned  To take accessory
noted patient on advantage of muscles for
Moderate high gravity breathing.
 Productive back rest. decreasing
cough, yellowish pressure on Goal met.
to greenish in the diaphragm
color. and enhancing
drainage of
 Positive Crackles different lung
segments.
 VII. NURSING CARE PLAN

 Encourage  This loosen up

increase fluid all the formed
intake. secretions of
the lungs.

 Assists patient  This will

on chest improve
physiotherapy cough when
pain is
inhibiting
effort

 Auscultate  This ascertain

breath sounds status and
and assess air progress.
movement.

 Administer
medication as
prescribed

PLANNING INTERVENTIONS RATIONALE EVALUATION

ASSESSMENT NURSING
DIAGNOSIS
 VII. NURSING CARE PLAN

Subjective cue: Ineffective After 1-2 hours of  Advise increase  To liquefy After 2hrs of
“Medyo nahihirapan breathing pattern Nursing fluid intake secretion nursing
ako huminga pero related to intervention: intervention:
konti lang,” as retained
 Perform Chest  To facilitate
verbalized by the secretions The client will Patient was able
client. loosen secretions Physiotherapy expectoration to expectorate
in the lungs. (Back Tapping) s of retained secretions and
Objective cues: secretions maintained airway
clearance as
 RR: 28 cpm  Administer  to facilitate evidenced by:
medications as fast recovery
 Use of accessory  RR: 19 cpm,
ordered
muscles for  Calmness
breathing and,
 Check the  As baseline  not using
 Restlessness consistency of data for accessory
noted secretions medication muscles for
breathing.
administration
 Productive
cough, yellowish Goal met.
 Instruct patient  To prevent
to greenish in
color. to expectorate further
the mucus retention of
 Positive Crackles secretion secretions

 Administer  For
 VII. NURSING CARE PLAN

medication as pharmacologic
ordered relief of
condition

PLANNING INTERVENTIONS RATIONALE EVALUATION

ASSESSMENT NURSING
 VII. NURSING CARE PLAN

DIAGNOSIS

Subjective cue: Thermoregulation After 2hrs of  Identify  This will give After 2hrs of
“Nilalagnat ako ng , Nursing underlying as the clue of nursing
apat na araw na. Ineffective related intervention: cause what are the intervention:
Pawala-wala siya,” as to Disease Process causes of
verbalized by the (presence of Patient’s sudden rise of Patient’s temp
patient. infection) as temperature will temp. subsided from
manifested by subside from 38.5˚C to 37.6˚C
Objective cues: elevated body 38.5˚C – 37.5˚C  Promote  Heat loss by
 Temp: 38.5˚C temperature, surface cooling radiation and Goal partially met.
 Skin is warm to 38.5˚C by means of conduction
touch undressing.
 Flushed skin  
noted  TSB.  Heat loss by
evaporation

 Monitor use of  This will

hyperthermia minimize
blankets shivering and
avoid rebound
effect of TSB

 Administer  This will

replacement support
fluids and circulating
electrolytes. volume and
tissue
perfusion.
VII. NURSING CARE PLAN