NURSING CARE PLAN
DATE
CUES
NEEDS
NURSING
DIAGNOSIS
OBJECTIVES OF
CARE
NURSING
INTERVENTION
EVALUATION
Subjective Cues
August
18, 2024
7/3 shift
The patient
verbalized:
1. "Lisod kaayo ang
akong pagginhawa,
mura'g naa’y gahi
nga nagbara sa
akong dughan."
2. "Maglisod ko ug
pag-ubo, di
makuhaan ang
plema."
3. “Ug akong I rate
kay 7/10 jud akong
pagkalisod sa
ginhawa ay”
Objective Cues:
1. Dyspnea (difficulty
of breathing)
Physiological
Needs:
Oxygenation.
Ineffective Airway
Clearance related to
airway obstruction as
evidenced by
Rationale: The
nursing diagnosis dyspnea.
of Ineffective
Airway Clearance Rationale: Ineffective
directly relates to Airway Clearance
occurs when a patient
the most
fundamental level is unable to effectively
clear secretions or
of Maslow’s
obstructions from the
hierarchy of
respiratory tract,
needs:
leading to
physiological
compromised airway
needs, which
include essential patency. This condition
functions such as is often related to
factors such as mucus
breathing,
oxygenation, and accumulation,
bronchospasm, or
homeostasis.
Ineffective airway inflammation, resulting
clearance, due to in airway obstruction.
The presence of
airway
After the nursing
1. Administer
interventions, the
Prescribed Oxygen
patient will be able to: Therapy
Rationale: Providing
 achieve an
supplemental oxygen
oxygen
can increase oxygen
saturation level
saturation levels,
of 95% or higher ensuring adequate
within 2 hours
oxygen delivery to
after the
tissues and reducing
initiation of
the workload on the
oxygen therapy respiratory system.
and breathing
Author: Potter, P. A., &
exercises.
Perry, A. G. (2016).
 report a
Fundamentals of
reduction in
Nursing.
dyspnea from a
2. Reposition the
severity of 7/10
to 4/10 or lower Patient in Semiwithin 4 hours of Fowler's Position
Rationale: Elevating the
implementing
head of the bed helps to
bronchodilator
maximize lung
GOAL MET
As evidenced by:
1. achieved an oxygen
saturation level of 95%
or higher within 2 hours
after the initiation of
oxygen therapy and
breathing exercises.
- Objective Cue: The
patient’s oxygen
saturation level
improved to 96% after
1.5 hours of oxygen
therapy, meeting the
target level.
- Subjective Cue: The
patient reported, "Mas
okay na akong
observed as the
patient struggles to
take deep breaths,
often appearing
breathless even at
rest.
2. Abnormal breath
sounds such as
wheezing upon
auscultation
3. Use of accessory
muscles or breathing,
with noticeable
intercostal retraction
during inspiration.
4. Increased
respiratory rate of 26
cpm (tachypnea)
5. Decreased oxygen
saturation (SpO2)
levels of 88% on
room air
6. Weak and
Ineffective Cough
7. Cyanosis of lips
obstruction,
poses a
significant threat
to these
physiological
needs by
impairing the
body’s ability to
obtain and utilize
oxygen, which is
vital for cellular
function and
overall survival.
Without adequate
oxygenation, the
individual’s ability
to meet even
basic survival
requirements is
compromised,
which can lead to
severe
consequences if
not promptly
addressed.
Reference:
Maslow, A. H.
(1943). A Theory
of Human
Motivation.
Psychological
dyspnea, characterized
by difficulty breathing,
is a key indicator, as
the patient struggles to
maintain adequate
airflow. This can lead
to impaired gas
exchange, reduced
oxygen saturation, and
respiratory distress.
(Herdman &
Kamitsuru, 2018).


Reference:
Herdman, T. H., &
Kamitsuru, S. (2018).
NANDA International
Nursing Diagnoses:
Definitions and
Classification, 20182020. Thieme Medical
Publishers.

therapy and
repositioning.
will demonstrate
effective airway
clearance by
expectorating
secretions and
reducing sounds
of wheezing
within 24 hours.
stabilize the
respiratory rate
within the
normal range of
12-20 breaths
per minute
within 6 hours of
starting chest
physiotherapy
and controlled
breathing
techniques.
remain free from
signs of
respiratory
complications
(cyanosis, use
of accessory
muscles)
expansion and reduces
the pressure on the
diaphragm, which
facilitates breathing and
improves oxygenation.
Author: Hinkle, J. L., &
Cheever, K. H. (2017).
Brunner & Suddarth's
Textbook of MedicalSurgical Nursing.
3. Administer
Prescribed
Bronchodilators
Rationale:
Bronchodilators relax
the bronchial muscles,
reducing airway
resistance and
improving airflow, which
alleviates dyspnea and
promotes airway
clearance.
Author: Lewis, S. L.,
Bucher, L., Heitkemper,
M. M., & Harding, M. M.
(2019). MedicalSurgical Nursing:
Assessment and
Management of Clinical
Problems.
pagginhawa, dili na
kaayo bug-at."
2. reported a reduction
in dyspnea from a
severity of 8/10 to 4/10
or lower within 4 hours
of implementing
bronchodilator therapy
and repositioning.
- Subjective Cue: The
patient stated, "Mura'g
gamay na lang akong
lisod sa pagginhawa, dili
na parehas ganiha."
The patient rated their
dyspnea at 3/10 after
3.5 hours.
3. demonstrated
effective airway
clearance by
expectorating secretions
and reducing sounds of
wheezing within 24
hours.
- Objective Cue: The
patient successfully
Review, 50(4),
370–396.
throughout the
next 48 hours
4. Encourage
Controlled Breathing
Techniques (PursedLip Breathing)
Rationale: Pursed-lip
breathing slows the
respiratory rate,
prolongs expiration, and
prevents airway
collapse, enhancing
ventilation and reducing
dyspnea.
Author: Gulanick, M., &
Myers, J. L. (2017).
Nursing Care Plans:
Diagnoses,
Interventions, and
Outcomes.
5. Perform Chest
Physiotherapy
Rationale: Chest
physiotherapy, including
percussion and
vibration, helps mobilize
secretions in the lungs,
making them easier to
expectorate, thereby
improving airway
clearance.
Author: Ackley, B. J., &
expectorated thick
mucus during chest
physiotherapy, and
subsequent auscultation
revealed less audible
sounds of wheezing
- Subjective Cue: The
patient expressed,
"Nakaluwa na jud ko ug
daghang plema, mas
gaan akong pagginhawa
karon."
4. stabilized respiratory
rate within the normal
range of 12-20 breaths
per minute within 6
hours of starting
respiratory
interventions, such as
chest physiotherapy and
controlled breathing
techniques.
- Objective Cue: The
patient’s respiratory rate
was recorded at 19
breaths per minute after
5 hours of respiratory
interventions, indicating
Ladwig, G. B. (2017).
Nursing Diagnosis
Handbook: An
Evidence-Based Guide
to Planning Care.
6. Encourage
Adequate Hydration
Rationale: Ensuring the
patient is well-hydrated
helps to thin mucus
secretions, making
them easier to
expectorate and
reducing airway
obstruction.
Author: Smeltzer, S. C.,
& Bare, B. G. (2014).
Brunner & Suddarth's
Textbook of MedicalSurgical Nursing.
7. Provide Humidified
Air
Rationale: Humidified
air helps to moisten
airway passages,
reducing irritation and
preventing thick, sticky
secretions that are
difficult to clear.
Author: Taylor, C., Lillis,
stabilization within the
normal range.
- Subjective Cue: The
patient noted, "Dili na
kaayo kusog ug paspas
akong pagginhawa, mas
normal na."
5. remained free from
signs of respiratory
complications (cyanosis
and use of accessory
muscles) throughout the
next 48 hours
- Objective Cue:
Throughout the 48-hour
period, there were no
signs of cyanosis, and
the patient did not
exhibit any use of
accessory muscles for
breathing.
C., & Lynn, P. (2015).
Fundamentals of
Nursing: The Art and
Science of PersonCentered Care.
8. Assist with or
Perform Suctioning as
Needed
Rationale: Suctioning
removes accumulated
secretions from the
airway when the patient
is unable to effectively
clear them, preventing
airway obstruction and
improving oxygenation.
Author: Elkin, M. K.,
Perry, A. G., & Potter,
P. A. (2013). Nursing
Interventions and
Clinical Skills.
9. Educate the Patient
on Effective Coughing
Techniques
Rationale: Teaching the
patient how to cough
effectively, such as
using the "huff cough"
technique, enhances
their ability to clear
secretions from the
airway, reducing
obstruction and
improving breathing.
Author: Swearingen, P.
L. (2016). All-In-One
Care Planning
Resource.