it includes the nursing care plan examples related to the respiratory system and their intervention in ideal format. check this for your reference. it help us to know the planning. its given according to NANDA nursing diagnosis.

1. NURSING
CARE PLAN

2. EXAMPLE OF RESPIRATORY SYSTEM

3. NURSING ASSESSMENT
• Note changes suggesting increased work of breathing (tachypnea, diaphoresis, intercostal
muscle retraction, fatigue) or pulmonary edema (fine, coarse crackles or rales, frothy pink
sputum).
• Assess breath sounds.
– Diminished or absent sounds indicate inability to ventilate the lungs sufficiently to prevent
atelectasis.
– Crackles indicate ineffective airway clearance, fluid in the lungs

4. Conti..
– Wheezing indicates narrowed airways and bronchospasm.
– Rhonchi and crackles indicate ineffective secretion clearance.
• Assess level of consciousness (LOC) and ability to tolerate increased work of breathing.
– Confusion, rapid shallow breathing, abdominal paradox (inward movement of abdominal
wall during inspiration), and intercostal retractions suggest inability to maintain adequate
minute ventilation.
• Assess for signs of hypoxemia and hypercapnia

5. • Determine vital capacity (VC), respiratory rate, and negative inspiratory force (NIF) and
compare with values indicating need for mechanical ventilation:
– VC < 10 to 15 mL/kg.
– Respiratory rate > 35 breaths/minute.
– NIF <15 to 25 cm H2O.
• Analyze ABG and compare with previous values.
– If the patient cannot maintain a minute ventilation sufficient to prevent CO2 retention, pH
will fall.
– Mechanical ventilation or noninvasive ventilation may be needed if pH falls to 7.30 or below.

6. Conti..
• Determine hemodynamic status (blood pressure, pulmonary wedge pressure, cardiac output,
Svo2) and compare with previous values. If patient is on mechanical ventilation and positive
end-expiratory pressure (PEEP), venous return may be limited, resulting in decreased cardiac
output.

7. Nursing Diagnoses
• Impaired Gas Exchange related to inadequate respiratory center activity
or chest wall movement, airway obstruction, and/or fluid in lungs
• Ineffective Airway Clearance related to increased or tenacious secretions
• Ineffective Airway Clearance related to sputum production

8. Conti..
• Acute Pain related to inflammatory process and dyspnea
• Risk for Injury secondary to complications
• Ineffective Tissue Perfusion (Pulmonary) related to decreased blood
circulation
• Anxiety related to dyspnea, pain, and seriousness of condition
• Risk for Injury related to altered hemodynamic factors and anticoagulant
therapy

9. Nursing Diagnosis
• Ineffective Breathing Pattern related to pulmonary infection and potential
for long-term scarring with decreased lung capacity
• Risk for Infection related to nature of the disease and patient's symptoms
• Imbalanced Nutrition: Less Than Body Requirements related to poor
appetite, fatigue, and productive cough
• Noncompliance related to lack of motivation and long-term treatment

10. ASSESSMENT
NURSING
DIAGNOSIS
GOAL /
EXPECTED
OUTCOME
INTERVENTION / PLANNING
IMPLEMENTAT
ION
RATIONAL EVALUATION
Subjective
data -
Impaired gas
exchange related
to inadequate
respiratory
center activity or
chest wall
movement,
airway
obstruction,
and/or fluid in
lungs
Improving
gas
exchange
Assess general condition of
patient
Assessment is
done
To know the
baseline data
and for patients
cooperation
Respiratory
rate and ABG
values within
patient's are
at normal
limits
Administer antibiotics,
cardiac medications, and
diuretics as ordered for
underlying disorder.
Medication
given
To improve the
condition of
patient
Administer oxygen Oxygen
therapy
provided
To maintained
oxygen
saturation in the
body

11. ASSESSMENT
NURSING
DIAGNOSIS
GOAL /
EXPECTED
OUTCOME
INTERVENTION / PLANNING IMPLEMENTATION RATIONAL EVALUATION
OBJECTIVE
DATA=
Impaired gas
exchange related
to inadequate
respiratory center
activity or chest
wall movement,
airway
obstruction,
and/or fluid in
lungs
Improving
gas
exchange
Monitor fluid balance by
intake and output
measurement
Intake and output
charts maintained
To detect
presence of
hypovolemia or
hypervolemia
Respiratory
rate and ABG
values within
patient's are
at normal
limits
Monitor adequacy of
alveolar ventilation by
frequent measurement of
respiratory rate, VC,
inspiratory force, and ABG
levels.
Vital signs taken To know the
lungs functions.
Give comfortable position Fowlers position
given
To breath
properly and feel
comfort
Checked oxygen saturation
of patient
Saturation
maintained
To know the
oxygen level of
the body

12. ASSESSMENT
NURSING
DIAGNOSIS
GOAL /
EXPECTED
OUTCOME
INTERVENTION / PLANNING
IMPLEMENTAT
ION
RATIONAL EVALUATION
Subjective
data -
Ineffective
airway
clearance
related to
increased or
tenacious
secretions
Maintaining
airway
clearance
Assess general condition of
patient
Assessment is
done
To know the
baseline data and
for patients
cooperation
Decreased
secretions;
lungs clear
Administer medications to
increase alveolar ventilation
that is bronchodilators and
corticosteroids
Medication is
given
Bronchodilators to
reduce
bronchospasm,
corticosteroids to
reduce airway
inflammation.
Checked vitals of patient Vitals are
taken
To know the vital
statistics
Perform chest physiotherapy Physiotherapy
is performed
To remove mucus

13. ASSESSMENT
NURSING
DIAGNOSIS
GOAL /
EXPECTED
OUTCOME
INTERVENTION / PLANNING
IMPLEMENT
ATION
RATIONAL EVALUATION
Objective
data -
Ineffective
airway
clearance
related to
increased or
tenacious
secretions
Maintaini
ng airway
clearance
Teach slow, pursed-lip breathing Breathing
exercises
taught
To reduce airway
obstruction.
Decreased
secretions;
lungs clear
Administer I.V. Fluids and
mucolytics
Administered To reduce sputum
viscosity.
Suction patient as needed To assist with
removal of
secretions.
Administer steam inhalation Steam is
given
To clear the airway
and decrease the
secretions

14. ASSESSME
NT
NURSING
DIAGNOSIS
GOAL /
EXPECTED
OUTCOME
INTERVENTION / PLANNING
IMPLEMENTATI
ON
RATIONAL
EVALUATIO
N
Subjective
data -
Ineffective
Airway
Clearance
related to
sputum
production
Establishing
Effective
Airway
Clearance
Assess general condition of
patient
Assessment is
done
To know the
baseline data and
for patients
cooperation
Coughs up
clear
secretions
effectively
Administer medications to
increase alveolar ventilation
that is bronchodilators and
corticosteroids
Medication is
given
Bronchodilators to
reduce
bronchospasm,
corticosteroids to
reduce airway
inflammation.
Checked vitals of patient Vitals are taken To know the vital
statistics
Objective
data -
Perform chest physiotherapy Physiotherapy is
performed
To remove mucus

15. ASSESSMENT
NURSING
DIAGNOSIS
GOAL /
EXPECTED
OUTCOME
INTERVENTION / PLANNING IMPLEMENTATION RATIONAL
EVALUATIO
N
Subjective
data -
Ineffective
Airway
Clearance
related to
sputum
production
Establishing
Effective
Airway
Clearance
Teach slow, pursed-lip
breathing
Breathing exercises
taught
To reduce
airway
obstruction.
Coughs up
clear
secretions
effectively
Give steam inhalation and
nebulization to patient
Steam and
nebulization is given
To expell out the
secreations
Clear the airway by doing
suction
Suctioning is done To clear the
airway
Objective
data -

16. ASSESSMENT
NURSING
DIAGNOSIS
GOAL /
EXPECTED
OUTCOME
INTERVENTION / PLANNING
IMPLEMENTA
TION
RATIONAL
EVALUATIO
N
Subjective
data -
Acute Pain
related to
inflammatory
process and
dyspnea
Relieving
Pleuritic
Pain
Assess general condition of patient Assessment is
done
To know the
baseline data
and for patients
cooperation
Appears
more
comfortable
; free of
pain
Place in a comfortable position
(semi-Fowler's) for resting and
breathing
Semifowlers
position given
To improve
breathing
encourage frequent change of
position
Changed
position every
two hourly
to prevent
pooling of
secretions in
lungs.
Objective
data -
Demonstrate how to splint the
chest while coughing
Supported to
chest while
coughing
To feel comfort

17. ASSESSMENT
NURSING
DIAGNOSIS
GOAL /
EXPECTED
OUTCOME
INTERVENTION / PLANNING
IMPLEMENTATI
ON
RATIONAL EVALUATION
Subjective
data -
Acute Pain related
to inflammatory
process and
dyspnea
Relieving
Pleuritic
Pain
Administer prescribed analgesic Analgesics
given
To reduce pain
level
Appears
more
comfortable;
free of pain
Objective data
-
Apply heat and/or cold to chest as
prescribed.
Heat
compression is
applied
To reduce pain
Administer oxygenation Oxygen provided To reduce dyspnea

18. ASSESSMENT
NURSING
DIAGNOSIS
GOAL /
EXPECTED
OUTCOME
INTERVENTION / PLANNING IMPLEMENTATION RATIONAL
EVALUATIO
N
Subjective
data -
Risk for Injury
secondary to
complications
Monitorin
g for
Complicati
ons
Assess general condition of
patient
Assessment is
done
To know the baseline
data and for patients
cooperation
Fever
controlled
, no signs
of
resistant
infection
Monitor vital signs Vital signs are
monitored
to assess the patient's
response to therapy.
Auscultate lungs and heart Lungs and heart
is ascultate
Heart murmurs or
friction rub may
indicate acute
bacterial endocarditis,
pericarditis, or
myocarditis
Objective
data -
Maintain intake and output Intake and
output is
maintained
To feel comfort