CHAPTER VIII

NURSING CARE PLAN

Assessment Diagnosis Planning Intervention Rationale E

Subjective Data: Ineffective airway After 8 hours of nursing Independent: GOAL PA
clearance related to interventions, the patient Assessed vital signs To serve as a baseline data After 8 ho
“Inuubo siya pero dry”, retained secretions will be able to: and check the general interventi
as verbalized by the characterized by condition of the patient verbalized
mother. unproductive cough - Maintain airway better but
patency This is to ensure that the unproduc
Objective Data: - Expectorate secretions Monitored and client is receiving the right there is a
regulated IVF amount of IV fluid, and to reassessm
VS taken accordingly prevent complications of IV plan of ca
T: 38.0*C infusion
RR: 33
PR:130 To meet the patient’s
O2 Sat: 98% comfort needs

Promoted rest Hydration can help improve

secretion clearance

Instructed the mother

and the client to
increase oral fluid
intake and avoid cold For treatment
drinks.

Dependent:
Administered
medication as ordered
by the physician