SYSTEMS PLUS COLLEGE FOUNDATION

Miranda Extension
Diploma in Health Care Technology

NURSING CARE PLAN

Name: ______________________ Date of Admission: ________________________

Data: Nursing Diagnosis Scientific Planning (Goal) Nursing Intervention Rationale Expected Outcome
Explanation
Subjective: Ineffective breathing An ineffective After 24 hours Independent: Independent: After 24 hours of
“nahihirapan pattern related to breathing pattern is of nursing -Determine the -to find out the nursing intervention
po Huminga si increased physical defined as inspiration intervention the presence of factors that is the patient was able
baby” As exertion as evidenced and/or expiration that patient will be factors/conditions a contributing to the to:
verbalized by by RR: 81 bpm, does not provide able to: noted in Defining illness. • Establish a
the patient. cyanosis, forceful adequate • Establish a characters normal, effective
intercostal & subcostal oxygenation. This normal, effective respiratory pattern
Objective: retraction diagnosis is related respiratory -assist with/review -to diagnose the as evidenced by
PR: 176 bpm to the observed rate pattern as results of necessary presence/severity absence of
RR: 81 bpm and depth of evidenced by testing. of lung disease cyanosis and other
Temp: 36.4°c breathing, as well as absence of signs/symptoms of
•Cyanosis abnormal chest cyanosis and -Avoid overfeeding, -Abdominal hypoxia with arterial
•Expiratory expansion, and other such as might occur distention can blood gasses
grunting accessory muscle signs/symptoms with young infant or interfere with (ABGs) within
•Nasal flaring use that results in a of hypoxia with client on tube feeding. breathing as well clieant’s normal or
•Forceful breathing pattern arterial blood as increase the acceptable range.
intercostal and that does not supply gasses (ABGs) risk of aspiration. • the family was
subcostal adequate ventilation within clieant’s able to demonstrate
retractions. to the body. normal or -review environmental -that may require appropriate coping
acceptable factors (e.g., avoidance of behaviors.
range. exposure to dust, high triggers or
• the family pollen counts, severe modification of
should be able weather, perfumes, lifestyle or
to demonstrate animal dander, environment to
appropriate household chemicals, limit the impact on
coping fumes, secondhand the client’s
behaviors. smoke; insufficient breathing.
home support for safe
care)
Dependent:
Dependent: -for management
-Administer oxygen at of underlying
the lowest pulmonary
concentration condition,
indicated and respiratory
prescribed respiratory distress, or
medications. cyanosis.

-To facilitate
-Provide use of deeper respiratory
adjuncts, such as effort.
incentive spirometer.