Nursing Care Plan by: Ahang, Nurhidaya J.
PLANNING
ASSESSMENT NURSING DIAGNOSIS OBJECTIVE OF IMPLEMENTATION EVALUATION
INTERVENTION RATIONALE
CARE
Subjective Cues: Ineffective airway After 8 hours of nursing Independent: After 8 hours of
clearance related to intervention, the client is performing patient
The client verbalized that obstruction or presence of able to: Encourage client to By staying hydrated, the Advised client to drink at interventions the client’s
his nose is very itchy and thickened secretions increase fluid intake mucus inside of the nose least 2 liters of water condition had improved
he is unable to breathe secondary to allergic stays thin and moist, everyday. as evidenced by:
through his nose especially rhinitis allowing the cilia to push
at night Breathe through his nose debris, bacteria and viruses
and not the mouth. out of the sinuses to No longer breathing
prevent infection. through the mouth.
Verbalize clearance of
the airway, especially the Advice client to blow Gently blowing the nose Told client how to
nose. nose regularly removes mucus or irritants correctly blow the nose to Normal airway clearance
Objective Cues: that are present. remove mucus and especially the nose.
Sleep for 6-8 hours a irritants.
day.
● Frequent sneezing Instruct client to change This position facilitates Changed the bed’s angle to Sleeping 6-8 hours a day.
● Nasal flaring Know and understand into semi or high fowler’s lung expansion and better facilitate the semi-fowler's
● Red and watery about the disease and position breathing. position while resting and
eyes treatment. only doing some activities. Being aware the disease
● Nasal congestion and treatment.
● Runny nose Teach client to use nasal Nasal sprays flush the nose Taught and demonstrated
● Cough sprays of irritants and help thin to the client how to use the
the mucus and reduce the saline nasal spray.
inflammation and helps pt
Diagnostic Procedures: breathe easier.
● Skin prick
(scratch) test Encourage thorough Furniture and equipment at Did health teaching about
● Allergen-specific cleaning of the house or home may house the dust the effects of dust and
immunoglobulin E the environment or pollen that triggers the other pollen to the client.
(IgE) antibody test allergic rhinitis.
● Intradermal skin
test Instruct client to comply Medication compliance Encouraged client to
● Patch test to medication therapy will help the pt to recover adhere to medication.
● Challenge tests quickly.
● Nasal smear
Collaborative:
● CBC count with
differential Identify the allergen Identifying the allergen Identified the allergen
causing the allergic helps in preventing the through assessment and
rhinitis allergy in happening. the use of laboratory
results.
Dependent:
Administer oral This is the first-line Administered the
antihistamines and nasal treatment for the medications prescribed.
glucocorticoids (steroids) symptoms of allergic
delivered by a nasal rhinitis. These drugs have
spray. few side effects and
dramatically relieve
symptoms in most people.
Reference/s:
https://nurseslabs.com/allergic-rhinitis/
https://my.clevelandclinic.org/health/diagnostics/21495-allergy-testing
https://www.mayoclinic.org/diseases-conditions/nonallergic-rhinitis/diagnosis-treatment/drc-20351235
