Nursing Care Plan #2:

ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING NURSING RATIONALE EVALUATION

BASIS INTERVENTIONS

S: Ineffective Autoimmunity Objective: Independent: Independent: Objective:

“Nahihirapan akong airway At the end of 1. Monitor respirations 1. Breath sounds At the end of 15

huminga dahil sa clearance 15 minutes of and breath sounds. indicates minutes of

Enlargement of the
goiter sa leeg ko related to nursing respiratory nursing
thyroid gland
kaya walang tracheal interventions, 2. Assess for dyspnea, distress or interventions, the

masyadong hangin obstruction as the patient will stridor, “crowing” and accumulation of patient was able

na pumapasok”as manifested by be able to cyanosis. secretions. to maintain

Compression of
verbalized by the the presence of maintain patent patent airway as
the trachea
patient. accessory airway as 3. Perform suctioning 2. Indicates evidenced by

muscles upon evidenced by when necessary tracheal decreased

O: respiration. Airway decreased obstruction/laryn wheezing breath

- Presence of obstruction wheezing 4. Elevate the head of the geal spasms, sounds.

accessory breath sounds. patient’s bed and change requiring prompt

muscles position every 2 hours evaluation and Goal:

upon Presence of intervention/ At the end of 4

 respiration accessory muscles Goal: 5. Encourage the patient hours of nursing

- Visibly upon respiration At the end of 4 to perform deep breathing 3. Clears excess interventions, the

enlarged hours of and coughing exercises. secretions that patient was able

neck nursing blocks the to maintain a

- (+) interventions, Dependent: airway patient airway as

Wheezing the patient will 1. Administer evidenced by

breath be able to expectorants and 4. Takes noiseless

sounds upon maintain a bronchodilators as advantage of the respirations

auscultation patient airway prescribed by the gravity

- RR: 24 bpm as evidenced physician. decreasing

by noiseless pressure on the

respirations Collaborative: diaphragm and

1. Collaborate with the enhances

physician regarding the drainage or

assessment of the patient ventilation to

for necessary surgical different lung

procedures (e.g. fields.

thyroidectomy).

5. Helps

decrease the rate

of respirations.

Dependent:

1. Expectorants

helps expel

secretions, while

bronchodilators

helps to dilate

airways for

respiration.

Collaborative:

1. Surgical

procedures (e.g.
thyroidectomy)

greatly improves

respirations, as

well as breathing

patterns.