VII. NURSING CARE PLAN
Name: Mr. JRB Unit: Emergency Room Admitting Dx: CAP mod. Risk
Age/ gender: 54 years old/ Male CC: Fever for 4 days Attending Physician: Dr. Untalan
Nursing Diagnosis Prioritization SIGNIFICANCE
Ineffective airway clearance 1 In assessment (ABC), airway should
always be prioritized
Ineffective breathing pattern 2 Breathing should also be assess to know
if the client has access to airway, or need
mechanical support
Thermoregulation, ineffective 3 Thermoregulation is important sisce this
may lead to fluid volume deficit if not
given proper attention.

VII. NURSING CARE PLAN
NURSING
ASSESSMENT PLANNING INTERVENIONS RATIONALE EVALUATION
DIAGNOSIS
Subjective cue: Ineffective airway After 1-2 hours of Monitor This will After 2hrs of
“Medyo nahihirapan clearance related Nursing respirations and indicate the nursing
ako huminga pero to productive intervention: breath sounds respiratory intervention:
konti lang,” as cough as evidence noting rate and distress and
verbalized by the by cough. Patient will be able sounds. accumulations Patient was able
client. to expectorate of breath to expectorate
secretions and sounds. secretions and
Objective cues: maintain patent maintained airway
airway clearance. Evaluate client’s This will clearance as
cough reflex determine the evidenced by:
RR: 28 cpm
and swallowing patient’s
ability ability to RR: 19 cpm,
Use of accessory
muscles for protect Calmness
breathing airway. and,
not using
Restlessness Positioned To take accessory
noted patient on advantage of muscles for
Moderate high gravity breathing.
back rest. decreasing
Productive
pressure on Goal met.
cough, yellowish
the diaphragm
to greenish in
and enhancing
color.
drainage of
different lung
Positive Crackles segments.

VII. NURSING CARE PLAN
Encourage This loosen up
increase fluid all the formed
intake. secretions of
the lungs.
Assists patient This will
on chest improve
physiotherapy cough when
pain is
inhibiting
effort
Auscultate This ascertain
breath sounds status and
and assess air progress.
movement.
Administer
medication as
prescribed

VII. NURSING CARE PLAN
NURSING
ASSESSMENT PLANNING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
Subjective cue: Ineffective After 1-2 hours of Advise increase To liquefy After 2hrs of
“Medyo nahihirapan breathing pattern Nursing fluid intake secretion nursing
ako huminga pero related to intervention: intervention:
konti lang,” as retained
Perform Chest To facilitate
verbalized by the secretions The client will Patient was able
loosen secretions Physiotherapy expectoration to expectorate
client.
in the lungs. (Back Tapping) s of retained secretions and
Objective cues: secretions maintained airway
clearance as
Administer to facilitate evidenced by:
RR: 28 cpm
medications as fast recovery
RR: 19 cpm,
Use of accessory ordered
muscles for Calmness
breathing and,
Check the As baseline not using
Restlessness consistency of data for accessory
noted secretions medication muscles for
breathing.
administration
Productive
Goal met.
cough, yellowish Instruct patient To prevent
to greenish in to expectorate further
color.
the mucus retention of
secretion
Positive Crackles

VII. NURSING CARE PLAN
secretions
Administer
medication as
ordered For
pharmacologic
relief of
condition

VII. NURSING CARE PLAN
NURSING
ASSESSMENT PLANNING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
Thermoregulation, After 2hrs of Identify This will give After 2hrs of
Subjective cue:
Ineffective related Nursing underlying as the clue of nursing
“Nilalagnat ako ng
to Disease Process intervention: cause what are the intervention:
apat na araw na.
(presence of causes of
Pawala-wala siya,” as
infection) as Patient’s sudden rise of Patient’s temp
verbalized by the
manifested by temperature will temp. subsided from
patient.
elevated body subside from 38.5˚C to 37.6˚C
temperature, 38.5˚C – 37.5˚C Promote Heat loss by
Objective cues:
38.5˚C surface cooling radiation and Goal partially met.
Temp: 38.5˚C
by means of conduction
Skin is warm to
undressing.
touch
Flushed skin
TSB. Heat loss by
noted
evaporation
Monitor use of This will
hyperthermia minimize
blankets shivering and
avoid rebound
effect of TSB
Administer This will
replacement support

VII. NURSING CARE PLAN
fluids and circulating
electrolytes. volume and
tissue
perfusion.