St.

Anthony’s College
San Jose, Antique
Nursing Department
NAME:S.,C
AGE:4
Dr.: E
CC: cough with DOB NURSING CARE PLAN
CUES NURSING RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE: Ineffective Decreased rate of After 8 hrs of INDEPENDENT:
“Nabudlayan ang akun breathing pattern respiration nursing intervention, Elevated head of Elevation of the After 8 hrs of nursing
bata mag ginhawa” as related to post the client will the bed for about 30 bed facilitates intervention,
verbalized by the patient surgical state as experience lessened degrees and ask the respiratory the client manifested
folks manifested by Decreased difficulty of breathing client to assume dorsal function by use lessened difficulty of
nasal flaring, pale oxygenation to the as manifested by recumbent position. of gravity. It also breathing as manifested by
skin, slight tissues of the body decreased in RR from decreases pressure decreased in RR from 27 cpm
cyanotic nailbeds, 27 cpm to 20cpm with on the abdomen when to 20cpm with the absence of
rapid shallow the absence of nasal assuming the position. nasal flaring, and presence of
breathing, RR of Body compensates flaring, and presence - calm breathing.
27 cpm to the decreased of calm breathing. Encouraged deep - Promote chest
oxygen breathing exercises expansion
- Kept
environmental
Body increases pollution to a
OBJECTIVE: pulse rate and minimum
respiratory rate
rapid shallow breathing
VS noted:
BP :100/80 Difficulty of
T :36.4 breathing (rapid and
RR:24 shallow)
PR:90
O2:96