West Visayas State University

COLLEGE OF NURSING
La Paz, Iloilo City

NURSING CARE PLAN

Clustered Cues Nursing Rationale Outcome Criteria Nursing Rationale Evaluation

Diagnosis Interventions
Ineffective Ineffective airway The client will be Assess airway for Maintaining the
airway clearance clearance is the able to maintain a patency. airway is always
related to inability to clear patent airway by first priority
excessive mucus secretions from the managing especially in cases
production respiratory tract to secretions with of trauma,
maintain a clear hydration, neurological
airway. effective decompensation
coughing and or cardiac arrest.
COPD is a combination chest Auscultate lungs for
of a chronic physiotherapy as presence of normal
obstructive bronchitis, evidenced by or adventitious
emphysema and clear breaths breath sounds as in
asthma. Inflammation upon the following:
of the bronchi causes auscultation,
increased mucus eupnea, and a. decreased or a. These may
production and ability to cough absent breath indicate
chronic cough. in out secretions by sounds presence of
chronic bronhitis, the a mucus
lungs´ mucociliary plug or
defenses are impaired other major
and there is increased airway
susceptibility to obstruction.
infection. When
infection occurs, b. wheezing b. This may
mucus production is indicate
greater and the partial
bronchial walls airway
become inflamed and obstruction
thicken. The thick or
mucus and inflamed narrowing.
bronchi obstruct the
airways.
c. coarse c. These may
crackles indicate
presence of
secretions
Sources: along larger
Nurse’s Pocket Guide airways.
2008 11th Edition by
Doenges et al
Assess respiration; Abnormality
Medical-Surgical note quality, rate, indicates
Nursing 2004 7th rhythm, depth, respiratory
Edition by Black & flaring of nostrils compromise.
Hawks and dyspnea on
exertion, evidence
of splinting, use of
accessory muscles
and position for
breathing.

Assess hydration Airway clearance

status; skin turgor, is impaired with
mucus membranes, inadequate
tongue. hydration and
a. record kind and subsequent
amount of fluid secretion
intake. thickening.
b. record quality
and amount of
output.

Assess changes in Increasing

mental status; level confusion,
of consciousness restlessness and/
and orientation. or irritability can
be early signs of
cerebral hypoxia.
Lethargy and
somnolence are
late signs.

Assess changes in Tachycardia and

vital signs. hypertension may
be related to
increased work of
breathing and
hypoxia. Fever
may develop in
response to
retained
secretions or
atelectasis or may
be a
manifestation of
an infectious or
inflammatory
process.

Assess for cough Consider possible

effectiveness and causes for
productivity. ineffective like
respiratory
muscle fatigue,
severe
brochospasm or
thick tenacious
secretions.

Note presence of Abnormalities

sputum; assess may be a result of
quality, color, infection,
amount, odor, and bronchitis,
consistency. chronic smoking
or other
conditions. A sign
of infection is
discolored
sputum (no
longer clear or
white); an odor
may be present.

Assess for Pain can result in

abdominal or shallow breathing
thoracic pain; allow and an ineffective
client to identify cough.
factors causing
pain.

Assess the patient´s Fatigue can limit

physical capabilities cough
with activities of effectiveness.
daily living including
ability to
expectorate
sputum.

Encourage oral fluid Increased fluid

intake of up to 3 intake reduces
liters per day or the viscosity of
what is indicated. mucus produced
by the goblet cells
in the airways. It
is easier for the
patient to
mobilize
coughing.
Teach and These improve
demonstrate to productivity of
patient proper the cough,
coughing and facilitate
breathing clearance of
maneuvers. Allow secretions and
client to do return prevent
demonstrations. atelectasis.
a.pursed-lip Dyspnea may be
breathing reduced by
b. splinting pursed- lip
breathing or
diagphragmatic
breathing.

Teach patient about Chemical irritants

environmental and allergens can
factors that can increase mucus
precipitate production and
respiratory brochospasm.
problems like
exposure to dust
and allergens, and
pollution.
a. assess for history
of allergic reactions
to dust and other
known allergens.

Explain effects of Chemical irritants

smoking including and allergens can
secondhand smoke. increase mucus
production and
brochospasm
Collaborative:

Administer oxygen To loosen

as ordered. secretions.

Give antibiotics and Antibilaotics such

antituberculosis as as Co- amoxiclav,
prescribed. Clarithromycin
and
Antituberculosis
such as Myrin P
Forte inhibits
bacterial
replication and
prevent further
infection.

Administer PAI as To loosen

ordered. secretions.

Sources:
Nurse’s Pocket
Guide 2008 11th
Edition by Doengesa
et al

Medical-Surgical
Nursing 2004 7th
Edition by Black &
Hawks

Brunner and
Suddarth’s
Textbook of
Medical-Surgical
Nursing 2004 10th
Edition by Smeltzer
& Bare

Nursing Care Plans

2007 6th Edition
Gulanick/Myers