Name: F.M.V St.

Anthony’s College
Age: 50 y.o San Jose, Antique
Diagnosis: Acute Gastritis Nursing Department

NURSING CARE PLAN

CUES NURSING RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Time: 8:00am Ineffective Ineffective General Objectives: Independent: After 8 hours of nursing
Date: 09/23/19 Airway Airway After of nursing 1. Auscultate 1. To ascertain status intervention patient has maintain
Subjective: Clearance Clearance is interventions, patient will breath sound and note progress airway patency.
“Nabudlayan ako related to defined as the be able to: 2. Position client 2.&3. To maintain open
maginhawa”as retained inability to Specific Objectives: to semi airway and
verbalized by the secretions. clear secretions After 8 hours of nursing fowlers decrease diaphragm
patient. or obstructions intervention the patient position pressure and
Objective: from the will be able to: 3. Elevate head increase drainage to
 Presence of respiratory tract Maintain airway of the bed lung field
crackles to maintain a patency 4. Kept 4. To lessen irritants
 Orthopnea clear airway. environment that can further
 Presence of Use this allergen free irritate nasal airway
phlegm nursing 5. Encourage 5. To expel excess
diagnosis guide deep breathing secretions
V/S taken as follows: to formulate and coughing 6. Help liquefy
BP-130/80mmhg your ineffective reflexes secretions
T-36.5°c Airway 6. Encourage 7. To prevent further
PR-58cpm Clearance care warm fluids complications
RR-26 bpm plan.Retained versus cold
O2sat-99% secretion in the fluids
airway tract can 7. Observe for
impair the signs of
ventilation of respiratory
the patient. distress
Dependent: 1. To loosen secretion
1. Give for easy
expectorants expectoration
as ordered