STUDENT NURSES’ COMMUNTY

NURSING CARE PLAN - Bronchitis

ASSESSMENT DIAGNOSIS OBJECTIVE INTERVENTION RATIONALE EVALUATION
Subjective: Short term: Independent:

“Nahihirapan ako Ineffective airway After 8 hours of • Assess respiratory • Useful in evaluating • Patient display
huminga” (Im clearance related to nursing interventions rate, depth. Note use the degree or improved
having difficulty excessive, thickened the patient will: of accessory muscles, respiratory distress ventilation and
breathing) as mucous secretions. pursed lip breathing, and chronicity of the adequate
verbalized by the • Demonstrate Inability to speak. disease process. oxygenation of
patient. improved tissues and
ventilation and • Elevate head of the • Oxygen delivery Arterial blood
Objective: adequate oxygen. bed, assist patient may be improved by gases (ABGs)
assume position to upright position and within normal
• Presence of • Arterial blood ease work of breathing exercises range and free
rhonchi. gases (ABGs) breathing. Encourage to decrease airway from symptoms
within normal deep slow or pursed collapse, dyspnea of respiratory
• Ineffective range. lip breathing as and work of distress.
cough. individually tolerated breathing.
• No signs of or indicated.
• V/S taken as respiratory
follows: distress. • Routinely monitor skin • Cyanosis may be
and mucous peripheral in nail
T: 37.2 Long term: membrane color. beds or central in
P: 79 lips or earlobes.
R: 24 After months of Duskiness and
BP: 110/80 nursing interventions, central cyanosis
the patient: indicate advanced
hypoxemia.
• Ventilation or
oxygenation is • Encourage • Thick, tenacious,
adequate to meet expectoration of copious secretions
self care needs. sputum; suction when are major source if
indicated. ineffective airways.
Deep suctioning
may be required
when cough is
ineffective for
expectoration of
secretions.
STUDENT NURSES’ COMMUNTY
• Evaluate level of • During severe or
activity tolerance. acute respiratory
Provide calm and distress, patient may
quiet environment. be totally unable to
perform basic self
care activities
because of
hypoxemia and
dyspnea.

• Evaluate sleep • Multiple external

patterns, note report stimuli and presence
of difficulties and of dyspnea may
whether patient feels prevent relaxation
well rested. and inhibit sleep.

♦ Monitor vital signs and • Tachycardia,

cardiac rhythm.
dysrhythmias, and
changes in blood
pressure can reflect
effect of systemic
hypoxemia on
cardiac function.

Collaborative:

• Administer • May correct or

supplemental oxygen prevent worsening
as indicated by ABG of hypoxia.
results and patients
tolerance.