Nursing Care Plan: To Ascertain Status, Breath
Nursing Care Plan: To Ascertain Status, Breath
Nursing Care Plan: To Ascertain Status, Breath
Subjective: Ineffective airway After 2 hours of >Assessed breath sounds. > to ascertain status, breath Goal met, after 2 hours
“may sipon pa din clearance related nursing sounds suggest developing of intervention the
ako at inuubo pa to intervention pulmonary infection. patient shows behavior
minsan minsan” tracheabronchial patient will on maintained clear air
as verbalized by maintain airway >Monitored respiratory rate, > Respiration may remain way.
the patient. patency depth and working breathing. somewhat rapid because of
hyperthyroid state, but
development of respiratory
Objective: distress is indicative tracheal
>occasionally compression from edema or
productive cough hemorrhage.
>Maintained bed rest.
>cold > for patient to gain energy and
prevent or lessen fatigue.
>RR-22 >Encouraged deep breathing
and coughing exercise. > maintains clear airway and
ventilation. Although “routine”
coughing is not encouraged and
may be painful, it may be
>Encouraged increased fluid necessary to clear secretion.
intake like fruit juices.
> to help liquefy secretion, fruit
juices contain vitamins that can
>Due medication given such help to the patient.
co-amoxiclav and ascorbic
acid. > to fight the bacterial infection,
improve or make immune system
>Adviced on proper disposal strong.
of respiratory secretion.
> to avoid infecting others and
spreading the bacteria.
College of Nursing
Submitted by:
Glory Ann P. Cadalin
BSN IIIA
Submitted to: