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MEDICAL CENTER IMUS

Diversion Road, Palico IV, Imus, Cavite 4103



c. Nursing Care Plan
Ineffective Airway Clearance r/t accumulation of tracheobronchial secretions
Assessment Planning Nursing
Intervention
Rationale Expected
Outcome/Evaluation

Restlessness/i
rritability
Nasal flaring
Rales on both
lungs
Tachypnea
with RR
62bpm
Tachycardia
with 204 bpm
DOB
Cough
Presence of
secretion
Short term:
After 3-4 hours of
NI pt. will be able
to demonstrate
Airway clearance,
reduction of
secretion, RR
improve.
Long term:
After 2-3 days of
NI pt. will be able
to establish and
maintain airway
patency
monitor
/record vital
sign
assess patient
condition
elevate head
and encourage
frequent
position
changed
keep back dry
and loosen
clothing
Instruct S.O. to
provide an
increase fluid
intake for the
child
Instruct S.O. to
provide
adequate rest
periods for the
child
Give
Expectorant
and
bronchodilator
To obtain baseline
data
To know patient
general condition
To promote and
improve
ventilation
To promote
comfort and
adequate
ventilation
To liquefy the
secretions
Rest will prevent
fatigue and
decrease oxygen
demand to further
mobilize the
secretions
To clear airway
when secretions
are blocking
To indicate
increase oxygen
saturation
Short term:
After 3-4 hours of NI
pt. shall have
demonstrated improve
airway clearance
reduction of congestion
with clear breath
sounds and Improve
RR
Long term:
After 2-3 days of NI pt.
shall have established
and maintain airway
patency
MEDICAL CENTER IMUS
Diversion Road, Palico IV, Imus, Cavite 4103

s as ordered
Administer
oxygen and
bronchodilator
s as ordered
Provide
suctioning as
ordered







MEDICAL CENTER IMUS
Diversion Road, Palico IV, Imus, Cavite 4103

Impaired Gas Exchange r/t accumulation of sputum affecting O2 and CO2 transport
Assessment Planning Nursing Intervention

Rationale Expected
Outcome/Intervention
Restlessness
Irritability
DOB
Cough
Nasal flaring
Chest in drawing
Tachypnea
Presence of
secretion

Short Term:
After 6 hours of NI pt.
will be able to
demonstrate improve in
gas exchange
Improve respiratory rate
to normal

Long Term.:
After 1-2 days of NI pt.
will be able to
demonstrate improved
ventilation and adequate
oxygenation of tissue
absence of symptoms of
respiratory distress.
Monitor v/s
Elevate head and
encourage
frequent position
changed
Keep back dry
Promote
adequate rest
periods
Change position
every 2 hours
Keep
environment
allergen free
Suction secretion
PRN
Instruct patient to
increase fluid
intake of the
child
Administer
oxygen therapy
as ordered
To obtain
baseline data
To promote
maximal
inspiration
enhance
expectoration of
secretions in
order to improve
ventilation
To avoid
coughing
Rest will prevent
fatigue and
decreased
oxygen demand
To promote
drainage of
secretion
To reduce
irritants effects
on airways
To indicate to
increase oxygen
saturation
O2 therapy is
indicated
Short term:
Patient shall demonstrate
improvement in gas
exchange a decrease in
respiratory rate to
normal

Long term:
Patient shall demonstrate
Improved ventilation
And adequate
oxygenation of tissue
absence of symptoms of
respiratory distress

MEDICAL CENTER IMUS
Diversion Road, Palico IV, Imus, Cavite 4103

increase O2
saturation.




MEDICAL CENTER IMUS
Diversion Road, Palico IV, Imus, Cavite 4103

Disturbed Sleeping Pattern r/t Difficulty of Breathing
Assessment Planning

Nursing Intervention Rationale Expected
Outcome/Evaluation
Irritability
Restlessness
DOB
Nasal flaring
Patient may
manifest lack of
interest in
breastfeeding
tachypnea
Short term:After 3 hours
of nursing intervention
the parents will be able
to verbalize
understanding of sleep
disturbance and identify
interventions to promote
sleep for the child
Long term:
After 3 days of Nursing
Intervention parent will
be able to report
improvement in sleep
pattern of the child
monitor v/s
encourage parent
to increase intake
of milk for the
child
provide quiet
environment for
the child instruct
parent to provide
dim environment
for the child
advise parent to
provide
warm/cotton
blanket for the
child
instruct parent to
elevate the head
of the child


to obtain
baseline data
to promote
relaxation sleep
periods for child
to promote
comfort and
chills for the
child
to maximize lung
expansion of the
child and to
prevent DOB


Short Term:
After 3 hours of NI the
parent shall have
verbalized understanding
of sleep disturbance and
identified interventions
to promote sleep of the
child

Long term:
After 3 days of NI the
parent shall have
reported improvement in
sleep pattern of the
child.