RIVERSIDE COLLEGE, INC.

www.riverside.edu.ph
NURSING CARE PLAN
PATIENT: __P____________________________________ AGE: _____76____________ SEX: M
NURSING DIAGNOSIS RATIONALE INTERVENTION RATIONALE EVALUATION
• Excessive mucus production 1. Assess respiratory status 1. To help identify early signs of Short-Term Evaluation:
• DIAGNOSIS: and bronchoconstriction are such as respiratory rate, depth, worsening airway obstruction After 8 hours of nursing
Ineffective Airway Clearance common in patients with COPD and effort every 2 hours. and ensures timely intervention. interventions, patient's oxygen
related to excessive mucus exacerbation and pneumonia. Auscultate lung sounds every 4 saturation is consistently above
production, These conditions lead to airway hours and note for crackles, 90%, patient reports reduced
bronchoconstriction, and obstruction, making it difficult wheezes, or diminished breath shortness of breath and is able
airway inflammation for the patient to clear mucus sounds. Monitor oxygen to clear secretions effectively.
secondary to COPD effectively. saturation continuously with
exacerbation and pneumonia pulse oximetry. Long-Term Evaluation:
• Airway inflammation further After one week of nursing
narrows the airways, 2. Administer medications as 2. To relieve bronchoconstriction, interventions, patient exhibits
• SUBJECTIVE: exacerbating the obstruction prescribed such as reduce inflammation, and normal breath sounds, and
Patient reports: and impeding gas exchange. bronchodilators, corticosteroids, maintain adequate oxygenation. respiratory rate returns to
- Shortness of breath antibiotics and supplemental baseline. No signs of respiratory
(Dyspnea) • Decreased ciliary function in oxygen. distress are present, and the
- Difficulty in coughing up the respiratory tract, often due patient has improved mobility
mucus to chronic lung disease, 3. Promote airway clearance 3. To help mobilize and thin and activity tolerance.
- Feeling of chest tightness reduces the ability to move and encourage the patient to mucus, making it easier for the
Increased fatigue mucus out of the airways, perform deep breathing and patient to clear secretions from
leading to ineffective clearance. coughing exercises every 2 the airways Status: Goal Met
• OBJECTIVE: hours, provide chest
> Productive cough with • Impaired gas exchange physiotherapy as needed.
thick sputum results from the combination of 4. To increase the oxygen supply
> Use of accessory muscles airway obstruction and to the body, compensating for
during breathing ineffective mucus clearance, 4. Provide patient education impaired gas exchange due to
> Wheezing or crackles leading to decreased about the importance of adhering airway obstruction.
heard on auscultation oxygenation and increased to medication regimens,
> Cyanosis (bluish tint to lips work of breathing. especially bronchodilators and
or fingertips) antibiotics and teach patient
> Oxygen saturation below • The observed cyanosis, use of techniques to manage dyspnea,
90% on room air accessory muscles, and such as pursed-lip breathing.
> Increased respiratory rate wheezing or crackles on Instruct the patient to avoid
(Tachypnea) auscultation are all indicative of exposure to respiratory irritants,
the patient’s struggle to such as smoke or dust.
maintain airway patency.
5. Monitor and evaluate lung 5. To empower them to manage

Dr. Pablo O. Torre Street, Capitol Subdivision, Brgy. 5, Bacolod City, Philippines, 6100
 RIVERSIDE COLLEGE, INC.
www.riverside.edu.ph
GOAL: Schematic Diagram sounds and respiratory effort their condition and prevent
Short-term Goals: after interventions. Evaluate the future exacerbations.
After 8 hours of nursing Excessive Mucus Production effectiveness of coughing and
interventions, patient will be ↓ deep breathing exercises and
able to demonstrate effective Airway Obstruction monitor for signs of
coughing and clear airway ↓ improvement, such as easier
within 24-48 hours, patient’s Bronchoconstriction breathing and clear lung sounds.
oxygen saturation will remain ↓
above 90% on room air or Impaired Gas Exchange
prescribed supplemental ↓
oxygen and patient will report Ineffective Coughing
decreased dyspnea and ↓
increased ease of breathing Decreased Oxygenation
within 24 hours. ↓
Ineffective Airway Clearance
Long-Term Goals:
After one week or nursing
interventions, patient will be
free from signs of respiratory
distress such as cyanosis,
abnormal breath sounds, or
use of accessory muscles
and will maintain clear lung
fields on auscultation and
exhibit normal respiratory
patterns.

Dr. Pablo O. Torre Street, Capitol Subdivision, Brgy. 5, Bacolod City, Philippines, 6100