NURSING CARE PLAN

GOALS/
CUES/ NURSING NURSING
RATIONALE EXPECTED RATIONALE EVALUATION
ASSESSMENT DIAGNOSIS INTERVENTION
OUTCOMES

Subjective data: Ineffective airway Ineffective airway Within 8º of rendering INDEPENDENT: After 8º of rendering
clearance related to clearance is an inability nursing care, the patient nursing care, the goals
The mother verbalizes: pneumonia as evidence to clear secretions or will demonstrate: 1. Assess 1. Tachypnea, was partially met as
by fast breathing, obstructions from the rate/depth of respiration shallow respirations evidenced by:
increase and changes in respiratory tract to  Decrease in rate and chest movement. and asymmetric chest
“Ginahapo and bata movement are
ko.” rate and depth of maintain a clear airway. and depth of  Decrease in rate
respiration, cough, frequently present
respiration and depth of
dyspnea and nasal because of discomfort
Objective data: respiration
of moving chest wall
flaring.  Absence of and or fluid in lung.
 Fast Breathing dyspnea
 Increase and 2. Elevate 2. Lower diaphragm,
changes in rate head of bed or assist promoting chest
patient in a semi- expansion, aeration of
and depth of
fowler’s position with lung segments,
respiration mobilization and
pillow support.
 Cough expectoration of
 Dyspnea DEPENDENT: secretions.
 Nasal flaring
 T= 35.80C 1. Assist with/ monitor 1. Facilitates liquefaction
and removal of
P= 96 beats/min effects of nebulizer
secretions.
RR= 60 cycles/min treatments and other
respiratory
physiotherapy.