Taibah University

Al-Madinah Al-Munawara ‫جامعة طيبة‬

Kingdom of Saudi Arabia ‫المدينة المنورة‬
College of Nursing ‫المملكة العربية السعودية‬
Medical Surgical Department ‫كلية التمريض‬
‫قسم الجراحة الطبية‬

Nursing Care Plan (NCP)

Patient Name:____________________________ Unit:________________ Room/Bed No.:________ Medical Diagnosis:_________________________
Nursing Diagnosis Patient-Centered
Assessment Nursing interventions Rationale Evaluation
(in priority order) Goals
Subjective Cues: Ineffective Airway After 2 hours of 1- Respirations may be
Clearance related to nursing 1- Assess and monitor respirations and shallow and rapid, After 2 hours of
breath sounds, noting rate and sounds
Accumulation Of intervention , the (tachypnea, stridor, crackles, wheezes). with prolonged nursing
fluid ( fluid overload client will be able Note inspiratory and expiratory ratio. expiration in intervention,
) evidenced by to Maintain airway 2- Auscultate breath sounds. Note comparison to client was able to
patency with breath adventitious breath sounds (wheezes, inspiration. Maintain airway
- SOB sounds crackles, rhonchi). 2- Some degree of patency with
3- Monitor and graph serial ABGs, pulse
- crackle sound clear/clearing. oximetry, chest x-ray.
bronchospasm is breath sounds
bilaterally 4- Position head midline with flexion on present with clear/clearing.
Objective Cues: - Productive and appropriate for age/condition. obstructions in the
Demonstrate 5- Assist the patient to assume a position of airway and may or And
cough comfort (elevate the head of the bed,
- SOB behaviors to may not be manifested
have patient lean on an overbed table or
improve airway sit on edge of the bed) in adventitious breath Demonstrate
clearance, e.g., 6- Observe characteristics of cough sounds such as behaviors to
- crackle sound cough effectively (persistent, hacking, moist). Assist with scattered, moist improve airway
bilaterally and expectorate measures to improve the effectiveness of crackles (bronchitis); clearance, e.g.,
secretions. cough effort. faint sounds, with cough effectively
7- Demonstrate effective coughing and
- Productive deep-breathing techniques.
expiratory wheezes and expectorate
cough 8- Suction secretions as needed (emphysema); or secretions
9- Demonstrate chest physiotherapy, such absent breath sounds
as bronchial tapping when in cough, (severe asthma). Goal is partially
proper postural drainage. 3- Establishes a met
10- Administer bronchodilators if
prescribed. baseline for
monitoring
progression or
regression of disease
process complications.
 Taibah University
Al-Madinah Al-Munawara ‫جامعة طيبة‬
Kingdom of Saudi Arabia ‫المدينة المنورة‬
College of Nursing ‫المملكة العربية السعودية‬
Medical Surgical Department ‫كلية التمريض‬
‫قسم الجراحة الطبية‬

Nursing Diagnosis Patient-Centered

Assessment Nursing interventions Rationale Evaluation
(in priority order) Goals
4- Gain or maintain an
open airway.
5- Elevation of the
head of the bed
facilitates respiratory
function by use of
gravity
6- Cough can be
persistent but
ineffective, especially
if the patient is elderly,
acutely ill, or
debilitated. Coughing
is most effective in an
upright or in a head-
down position after
chest percussion.
7- Helps maximize
ventilation.
8- Suctioning clear
secretions that obstruct
the airway therefore
improves oxygenation
9- These techniques
will prevent possible
aspirations and prevent
any untoward
complications.
 Taibah University
Al-Madinah Al-Munawara ‫جامعة طيبة‬
Kingdom of Saudi Arabia ‫المدينة المنورة‬
College of Nursing ‫المملكة العربية السعودية‬
Medical Surgical Department ‫كلية التمريض‬
‫قسم الجراحة الطبية‬

Nursing Diagnosis Patient-Centered

Assessment Nursing interventions Rationale Evaluation
(in priority order) Goals
10- More aggressive
measures to maintain
airway patency.