NURSING CARE PROCESS

ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS EXPLANATION

Subjective cues: Ineffective airway The inflammatory After 4 hours of >Assessed >Use of accessory The client
“ Medyo clearance related response to nursing respiratory muscles to breathe maintained airway
nahihirapan pa to ineffective infection causes interventions, the movements and use indicates an abnormal patency as
akong huminga”. cough and tissue edema and client will be able of accessory increase in work of evidenced by
retained exudates formation to maintain airway muscles. breathing. (Nursing Care expectorating clear
Objective cues: secretions. in the lungs, the patency.
th
Plan, 6 edition,
secretions readily.
Gulanick/Myers pg. 480)
inflammatory
> Use of response can
accessory muscles >To obtain baseline
narrow and >Monitored vital
when breathing data. (Pediatric Nursing
potentially obstruct signs especially the
Care Plans, 3rd
bronchial passages RR.
edition,Karla L.
>crackles herad and alveoli. Luxner,RNC,ND,pg. 67)
upon percussion
(Medical- Surgical
>productive cough Nursing Critical
>Auscutated the >Bronchial lung
Thinking for
– whitish color lung sounds, noting sounds are commonly
collaborative care,
vol.1,5th edition, areas of decreased heard over areas of
>dyspneic Ignatius, et.al,page 978) ventilation and lung density or
 presence of consolidation.
>difficulty of adventitious sounds. Crackles are heard
vocalizing when fluid is present.
(Nursing Care Plan, 6th
edition, Gulanick/Myers pg.
>restlessness
480)

>These determine
progression of disease
>Monitored chest x
process. (Nursing Care
– ray reports.
Plan, 6th edition,
Gulanick/Myers pg. 480)

>Hydration helps
>Encouraged client decrease the viscosity
to increase fluid of secretions,
intake. facilitating
expectorations.
(Pediatric Nursing Care
Plans, 3rd edition,Karla L.
Luxner,RNC,ND,pg. 67)

>Positioning facilitates
chest expansion and
 respiratory efficiency
>Advised the by reducing pressure
realtives elevate the of abdominal organs
head of bed at least on diaphragm.
30 degrees. (Pediatric Nursing Care
Plans, 3rd edition,Karla L.
Luxner,RNC,ND,pg. 68)

> Relaxes bronchial

and uterine smooth
muscle by acting on
beta – adrenergic
>Assisted on
receptors. (MIMS page
nebulizer treatment.
345)
Nebulization done
as per doctor’s order >Chest physiotherapy
every 12 hours. helps to aid
immobilization of
secretions. (Nursing
>Chest tapping Care Plan,7th edition,
performed after Doenges, et.a pg 108l)

each nebulization.
>Discharges from the
nebulizer are often foul
 tasting and smelling.
(Nursing Care Plan, 6th
edition, Gulanick/Myers pg.
480)
>Instructed the
client to have oral
care after each
>Fluids are regulated
nebulization.
to replace losses and
aid immobilization
secretions.(Nursing Care
Plan,7th edition, Doenges,
>Provided et.a pg 108l)
supplemental fluids
-IV- D5 0.3 NaCl
500cc regulated at
30 mcgtts per
minute a per
doctor’s order.