NURSING CARE PLAN

ASSESSM NURSING PLANNING INTERVENTION RATIONALE EVALUATI

ENT DIAGNOS ON
IS
Subjectiv Ineffectiv After 1 week Independent: Independent Long
e e airway of nursing - Monitor - First and Term
“chest clearance intervention and/or foremost,
cold” for 2 related to ,the patient assess the the airway Goal Met
weeks ; accumula will be able respiration must always
shortness ted to; and airway be kept After 1
of breath mucus Long Term: patency open, week of
upon obstructi -The patient - Encourage particularly nursing
exertion; ng the will be able hydration in situations interventi
elevated airway to maintain at least 8 involving ons, the
temperat clear, open glasses of trauma, patient
ure airways as water/day rapid was able
“pain” in evidence by - Position cerebral to
her normal head decompens maintain
“lungs.” breath appropriat ation, or clear,
sounds, e for cardiac open
Objective normal rate condition arrest. airways as
s and depth such as - To loosen evidence
•inspirato of fowler’s secretion by normal
ry crackles respiration. position - To keep an breath
with - Teach the individual’s sounds,
diminishe patient airway open normal
d breath After 3 Days how to while they rate and
sounds in of nursing breathe are at rest depth of
the right intervention and cough or in a respiratio
lung , the patient correctly. compromis n.
will be able (For ed state.
to; example, -Coughing is
Short inhale the most Short
Term: deeply, practical Term
-The patient hold it for approach to
will be able two get rid of Goal Met
to classify seconds, most
methods to and then secretions. After 3
enhance cough Therefore, days of
secretion twice or helping the nursing
removal as three patient with interventi
evidence by times in this task is ons, the
ability to quick essential. patient
effectively succession Contrarily, was able
cough up ). deep to classify
secretions Dependent: breathing methods
after - Give encourages to
treatments medication oxygenation enhance
and deep s as prior to secretion
breaths. prescribed, deliberate removal
such as coughing. as
antibiotics, evidence
mucolytic Dependent: by ability
agents, - Different to
bronchodil drugs are effectively
ators, prepared to cough up
expectora address secretions
nts, noting different after
effectivene issues. Most treatment
ss and side encourage s and deep
effects. the removal breaths.
- Perform of
nasotrache secretions
al from the
suctioning airways and
as may lessen
necessary, airway
especially resistance.
if cough is - When
ineffective. patients are
- Educate weak, have
patient on thick mucus
coughing, plugs in
deep their
breathing, throats, or
and produce a
splinting lot of
techniques persistent
. mucus, they
need to be
Collaborative suctioned.
- The patient
- Find out if will
 the patient comprehen
is thinking d the
about fundamenta
using l idea and
herbal the
remedies appropriate
(e.g., ma methods for
huang for maintaining
bronchosp a secretion-
asm, free airway.
goldenseal Collaborative
for - It is
pneumoni necessary
a, and to consider
echinacea drug
for URTIs). interactions
- Coordinate with
with a prescription
respiratory drugs and
therapist contraindic
for chest ations.
physiother - Postural
apy and drainage
nebulizer and chest
manageme percussion
nt as are two
indicated. methods
- Teach used in
caregivers chest
proper physiothera
suctioning py to
methods. mobilize
Offer a secretions
chance for from tiny
a follow- airways that
up cannot be
demonstra removed
tion. Adapt with suction
methods or
for a coughing.
domestic - This
environme facilitates
nt. the efficient
and safe
clearance of
secretions
from the
airway..