Nursing Care Plan
Assessment Nursing Inference Planning
Diagnosis
Subjective: After 8 hours of nursing
“ Maganit ang pag- ubo Ineffective airway intervention, the client
ko na may kasamang clearance related to the client will be able to
plema”. increased sputum verbalize how to
production maintain a diet that is
Objective: high in fiber, low in sugar
- bubbling breath sound and carbohydrates.
- use of accessory muscle
- effective cough w/ After 8 hours the client
sputum production will be able to verbalize
- RR= 30cpm the importance of
exercise to avoid
sedentary lifestyle.
After 8 hours of
discussion, the client will
be able to demonstrate
the proper breathing
exercise and coughing
After 8 hours of
administering
Intervention Rationale Evaluation
Independent:
- Assess rate/ depth of -Tachypnea, shallow
respirations and chest respirations, and
movement asymmetric chest
movement are frequently
present because of
discomfort of moving
chest wall and/ or fluid in
lung
- Auscultate lung fields, -Decreased airflow
noting areas of occurs in consolidated
decreased/ absent airflow areas. Crackles, ronchi,
and adventitious breath and wheezes are heard on
sounds inspiration and expiration
in response to fluid
accumulation, thick
secretions, and airway
spasm
- Elevate the head of the -Lowers diaphragm,
bed, change position promoting chest
frequently expansion, mobilization
and expectoration of
secretions
- Assist patient with -Deep breathing
frequent deep breathing facilitates maximum
exercises. Demonstrate/ expansion of the lungs/
help patient learn to smaller airways.
perform coughing Coughing is natural self-
cleaning mechanism,
assisting the cilia to
maintain patent airways
Collaborative:
- Provide supplemental -Fluids are required to
fluids e.g. IV, humidified replace losses and aid in
oxygen mobilization of secretions
- Administer -Aids in reduction of
medications: mucolytics, bronchospasm as well as
expectorants, mobilization of secretion
bronchodilators as
ordered
ASSESSME NURSING INFERENCE PLANNING INTERVENTI RATIONAL EVALUATIO
NT DIAGNOSIS ONS E N
“Tumaas Risk for After 8 hours Provide
and sugar unstable the client will information on
level ko ng blood be able to balancing food
345 2 days glucose verbalize how intake,
bago ako na- related to to maintain a antidiabetic
admit” as Diabetes diet that is high agents, and
verbalized Mellitus as in fiber, low in energy
by the manifested sugar and expenditure.
patient. by blood carbohydrates.
“Nahihilo at serum level Discuss home To identify
nanghihina of 245. After 8 hours glucose and manage
din ako” as the client will monitoring glucose
verbalized be able to according to variations.
by the verbalize the individual
patient. importance of parameters.
exercise to
Blood serum avoid sedentary Review client’s Glucose
level of 245 lifestyle. diet; especially balance is
on the day carbohydrate determined
of After 8 hours intake. by the
admission. Type 2 Diabetes Mellitus occurs the client will amount of
when the pancreas produces be able to state carbohydrate
insufficient amounts of hormone the importance s consumed,
insulin and/or the body’s tissues of self- which should
become resistant to normal or monitoring of be
even high levels of insulin. This blood glucose. determined in
causes high blood glucose levels, needed
which can lead to a number of grams/day.
complications if untreated.

Encourage
client to read
labels and These foods
choose foods produce a
described as slower rise in
having a low blood
glycemic index, glucose.
higher fiber,
and low –fat
content.
Cruz, Margot Marie R.
III A

NAME OF PATIENT: Nida Medrana