VI.

NURSING CARE PLAN

ASSESSMENT DATA NURSING DIAGNOSIS GOALS AND OBJECTIVES NURSING INTERVENTIONS AND RATIONALE EVALUATION
(Problem and Etiology)
(Subjective & Objective Cues)

Subjective: Ineffective breathing pattern Short term goals: Independent: Goals met. The
related to fluid accumulation in patient was able to
“…. Galisud ko ug ginhawa ug mura ko the right mid-axillary line After 15 minutes of thorough 1.) Encourage adequate rest periods between improve her
gahangakon” secondary to pleural effusion nursing intervention, the activities respiratory rate
client will be able to: r – To limit fatigue and to preserve the use from 26cpm to
of energy. 24cpmdemonstrate
2.) Place patient in semi-fowlers position various ways in
Objective:
R – to promote proper lung expansion maintaining normal
a.) improve her
 RR: 26cpm (tachypneic) 3.) Assist client to learn breathing exercises; breathing pattern
respiratory rate from
 Presence of crackles diapraghmatic abdominal breathing, reduce water level
26cpm to 24cpm
 restlessness inspiratory resistive and pursed-lip as within the mid-
b.) demonstrate various
indicated axillary line.
ways in maintaining
R – to allow proper gas exchange.
normal breathing
pattern Dependent:
c.) reduce water level
within the mid- 1.) Administer O2 at lowest concentration, as
axillary line ordered.
R – to induce proper breathing
Long term goals:

a.) achieve a respiratory Collaborative:

rate between normal
range of 12-22cpm 1.) Refer patient for Chest Thoracostomy
b.) completely eliminate Tube insertion
the presence of fluid R – to drain aseptically excessive fluid
within the pleural in the right mid-axillary line
spaces specifically in
the right mid-axillary
line

ASSESSMENT DATA NURSING DIAGNOSIS GOALS AND OBJECTIVES NURSING INTERVENTIONS AND RATIONALE EVALUATION

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 VI. NURSING CARE PLAN
(Subjective & Objective Cues) (Problem and Etiology)

Subjective: Altered body temperature related Short term goals: Independent: Goal was met, the
to bacterial invasion in the lungs. patient manifested
“medyo init man ko..” At the end of 30 min. of 1.) Monitor Pt’s temperature every 30
normal body
nursing intervention the minutes.
temperature as
patient will be able to: R - To determine if the Pt’s temperature is
evidenced by
above the normal body temperature.
Objectives: temperature of
2.) Encourage Pt to increase fluid intake.
37.1°C and able to
 Febrile(38°C) a.) Manifests normal
R - To maintain hydration status and
Demonstrate ways
 RR – 26cpm (tachypneic) range of increased fluid intake helps lessen febrility.
in avoiding the
 restless temperature(36.6°C 3.) Perform tepid sponge bath.
reoccurrence of
-37.5°C) R - To promote surface cooling.
fever
b.) Demonstrate ways in
avoiding the Dependent:
reoccurrence of fever
1.) Administer paracetamol, an antipyretic
Long term goals: medication as prescribed.
R - Promotes return of body temperature
a.) Fully eliminate
presence of any to normal.
bacteria invading in
the lungs

ASSESSMENT DATA NURSING DIAGNOSIS GOALS AND OBJECTIVES NURSING INTERVENTIONS AND RATIONALE EVALUATION
(Problem and Etiology)

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 VI. NURSING CARE PLAN
(Subjective & Objective Cues)

Subjective: Ineffective airway clearance Short term goals: Independent: Goals met. The
realted to accumulation of copius 1. Assist the patient in positioning herself in a client was able to
“…. Galisud ko ug ginhawa ug mura ko mucous secretions After 15 mins of thorough semifowler’s position demonstrate
gahangakon” nursing interventions, the R = Putting the patient into a semifowler’s
improvement on
patient will be able to: position facilitates respiratory function by
her breathing
use of gravity smaller airways thus, it allows
proper lung expansion. pattern from
Objective:
2. Instruct the significant others of the patient 26cpm to 24cpm
 RR: 26cpm (tachypneic) a. Demonstrate improvement do not let the patient to wear tight clothes. and gradually
 Presence of crackles on her breathing pattern R = tight clothes makes the patient weary expectorate
 Restlessness from 26cpm to 24cpm. to breath because the feeling of being retained secretions
 Non-productive cough congested so it is advisable to have clothes
in her airways.
that are not too tight for her in order to
help the patient to breath effectively.
b. Gradually expectorate 3. Perform chest tapping to the patient.
retained secretions in her R = to help expectorate the retained
airways. secretions that are obstructing the airway.
4. Provide a well ventilated environment.
Long term goals: R = to promote proper lung expansion and
effective breathing pattern.
a.) Completely eliminate
presence of 5. Instruct the significant others of the patient
abnormal sounds to increase her fluid intake.
R = Fluids aid in the mobilization of
secretions

Dependent:

1. Administer bronchodilators as prescribed

by the physician.
R = for proper breathing pattern.

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