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Nursing Care Plan

Assessment Diagnosis Planning Intervention Rationale Evaluation


Subjective: Impaired Gas After 4 hours of Monitor respiratory To identify the After 4 hours of
exchange r/t nursing status every 4 indication providing nursing
Objective: altered delivery intervention he hours, blood gas toward intervention the
tachycardia of inspired patient will analysis and progress or patient was
Restlessness oxygen and air demonstrate input/output. deviations demonstrated
Nasal flaring trapping improved from the client. improved
Use of accessory ventilation and ventilation and
muscle adequate Place patient in Upright adequate
Presence of oxygenation of semi fowler position oxygenation of
Mechanical tissues as position. allowing good tissues as evidence
ventilator evidence by lung by normal
Abnormal arterial normal capillary expansion. capillary refill test.
pH refill test.
Pale in appearance Encourage adequate Helps limit
DOB rest, promote calm oxygen needs
and restful and
V/S: environment. consumption.
BP: 100/70
RR: 45 Keep environment To reduce
PR: 184 allergen and irritant effect
T: 38 pollutants free. to dust and
chemicals on
airway
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Ineffective airway After 4 hours if Keep To reduce After 4 hours of
Nahihirapan clearance r/t nursing intervention environment irritant effect to nursing intervention
siyang retained secretions patients secretions allergen and dust and clients secretion
huminga in the bronchi and will lessen pollutants free. chemicals on was lessen.
airway constriction airway
Objective:
Productive Encourage to To reduce
cough rest fatigue
Wheezing
Crackles on R Elevate head of To facilitate
and L bronchi bed lung expansion
Restlessness
Change position To take
V/S: every 2 hours advantage of
BP: 100/70 the gravity to
PR: 184 decrease
RR: 45 pressure on the
T: 38 diaphragm and
enhance
drainage.

Monitor child To avoid


for feeding compromised
intolerance and airway
abdomen
distension.

Assist in To maintain
suctioning clear and open
airway.
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Fluid volume After 4 hours of
deficit r/t nursing intervention
Objective: the patient will
Dry lips maintain fluid
Warm skin volume at a
Tachycardia functional level as
Tachypnea evidenced by stable
vital signs.
V/S:
BP: 100/70
PR:184
RR:45
T: 38.0