GOALS AND

ASSESSMENT DIAGNOSIS INTERVENTION EVALUATION

OBJECTIVES
IX. NURSING CARE PLAN
• Subjective Ineffective airway After 15 mins of INDEPENDENT: Goals partially met.
clearance related to thorough nursing
“ galisod ug ginhawa increased interventions, the patient 1. Assist the patient in positioning herself in After 15 minutes of
akong anak “ as production of will be able to: a semifowler’s position nursing interventions,
verbalized by the secretions the patient was able to
mother a. Demonstrate R = Putting the patient into a semifowler’s demonstrate
improvement on her position facilitates respiratory function by use of improvement on her
breathing pattern from gravity smaller airways thus, it allows proper breathing pattern from
• Objective 68cpm to 65cpm. lung expansion. 68cpm to 65cpm, and
gradually expectorate
- use of b. Gradually expectorate retained secretions in
accessory retained secretions in her 2. Instruct the significant others of the her airways but failed
muscle airways. patient do not let the patient to wear tight to decrease the use of
(opening of the clothes. her accessory
mouth and c. Breath effectively with muscles, specifically
moving the a minimal use of her R = tight clothes makes the patient weary to opening her mouth
shoulders when accessory muscles breath because the feeling of being congested while breathing.
breathing) (mouth and shoulders). so it is advisable to have clothes that are not
too tight for her in order to help the patient to
- abnormal breath effectively.
breath sounds

- RR – 68cpm 3. Perform chest tapping to the patient.

R = to help expectorate the retained secretions

that are obstructing the airway.

4. Provide a well ventilated environment.

R = to promote proper lung expansion and

effective breathing pattern.

5. Instruct the significant others of the

patient to increase her fluid intake.

R = Fluids aid in the mobilization of secretions

 IX. NURSING CARE PLAN

GOALS AND
ASSESSMENT DIAGNOSIS INTERVENTION EVALUATION
OBJECTIVES

• Subjective Acute pain related to After one hour of INDEPENDENT: Goals met.
persistent non- nursing interventions,
“ sige ug ubo-ubo productive cough the patient will be able 1. Perform chest tapping onto the patient. After one hour of
akong anak pero to: nursing interventions,
walay gagawas nga R = to help expectorate the retained secretions the patient was able to
phlema, muhilak a. Gradually that are obstructing the airway. gradually expectorate
dayon siya “ as expectorate the retained secretions in
verbalized by the retained secretions in her airways and also
mother her airways. 2. Assist patient with deep breathing perform things without
exercise. feeling of pain as
b. Perform things manifested by the
• Objective without the feeling of R = To promote a soothing feeling while absence of crying,
pain as manifested by promoting proper lung expansion. facial grimacing and
- fatigue the absence of crying, fatigue.
facial grimacing and
- facial grimace fatigue. 3. Perform distraction of the pain felt
 IX. NURSING CARE PLAN

through initiating various activities like

- crying giving her toys to play.

- no secretions R = to divert the attention of the patient to other

are being things instead focusing on her pain.
expectorated

- dry and harsh 4. Instruct the significant others of the

cough patient to increase her fluid intake.

R = Fluids aid in the mobilization of secretions

DEPENDENT:

1. Administer medications as prescribe:

mucolytics or expectorants.
R = to reduce the viscosity of the secretions
thus, promotes secreting the retained mucous.

2. Administer analgesics as order.

R = to reduce the pain felt by the patient.
 IX. NURSING CARE PLAN

GOALS AND
ASSESSMENT DIAGNOSIS INTERVENTION EVALUATION
OBJECTIVES
 IX. NURSING CARE PLAN

• Subjective Imbalance nutrition: After a month of INDEPENDENT: Goals met.

less than body thorough nursing
- “dili kayo requirements related intervention, the 1. Instruct the client’s parent to prepare After a month of
gakaon ug suso to loss of appetite. patient will be able to: foods with good presentation and tasty thorough nursing
akong anak” as yet nutritious and affordable. intervention, the
verbalized by a. Improve her Body patient was able to
the mother’s Mass Index from 17.5 R = to enhance food satisfaction and stimulate improve her Body
patient. to 20 through appetite. Mass Index from 17.5
increasing her weight to 20 by increasing
as well her height. 2. Assist client in performing proper oral her weight and height
• Objective care. and ate a whole share
b. Eat a whole share of of food and able to
- BMI: 17.5 food and breastfeed R = to promote better taste sensation, thus, breastfed with good
(weight: 6.3 kg) with good appetite. promoting food satiety and stimulate good appetite.
(height: 60cm) appetite.

- Restless 3. Promote pleasant, relaxing

environment including socialization, if possible.
- No appetite
R = to stimulate good appetite and better food
intake.

4. Discuss with the client’s parents the

importance of good nutrition.

R = in order to educate the significant others of

the client the essence of good nutrition and how
it will help in promoting fast recovery to the
patient’s existing condition.
IX. NURSING CARE PLAN

DEPENDENT:

1. Administer supplements as ordered.

R = in order to promote better appetite while

eating and also help achieving better nutrition.

COLLABORATIVE:

1. Refer the client to the dietician for the

proper diet that fits her.

R = to promote good nutrition.