zamora - ncp
Post on 09-Apr-2018
221 Views
Preview:
TRANSCRIPT
-
8/7/2019 Zamora - NCP
1/6
ZAMORA, Brylle S. Leadership and Management / Maam Jennifer Padual
BSN118 / Group 72 B February 10, 2011 / Head nurse: Karen Maeve Villa
NURSING CARE PLAN
CUES ANALYSIS NURSINGDIAGNOSIS
GOAL ANDOBJECTIVES
INTERVENTION RATIONALE EVALUATION
Subjective:N/A
Objective:
Vital signsRR 24 cpm
Temp 36.6
BP 110/60
PR 72 bpm
*patient isirritable
* patient iscrying
* increase inchestexpansion;noted.
Respiratorypatternmonitoringaddresses thepatientsventilatorypattern, rate,and depth.Most acutepulmonarydeterioration ispreceded by achange inbreathingpattern.Respiratoryfailure can beseen with achange inrespiratory rate,change innormalabdominal andthoracicpatterns for inspiration andexpiration,change in depth
Ineffectiveairwayclearancerelated todecreasedenergy or fatigue asmanifested byof accessorymuscles duringrespiratoryventilation andnasalcongestion.
After 24 hours ofnursing interventionthe client will be ableto have an improvedbreathing pattern.
After 8 hours of nursing interventionthe health careprovider will be ableto perform thefollowing:
1. Gain clientsattention andbuild affinity.
Talk to the client andinteract with him tohave his trust.
Assess airway forpatency.
Auscultate lungs forpresence of normalor adventitious
If the client iscomfortable with youbeing around,interventions will beeasier to execute.
Maintaining theairway is always thefirst priority, especiallyin cases of trauma,acute neurologicaldecompensation, orcardiac arrest.
After 24 hours ofnursingintervention theclient was able tomanifest signs ofimprovedbreathing.
-
8/7/2019 Zamora - NCP
2/6
of ventilation(Vt), andrespiratoryalternans.
Breathingpatternchanges mayoccur in amult itude ofcases fromhypoxia, heartfailure,diaphragmaticparalysis,airwayobstruction,
infection,neuromuscularimpairment,trauma or surgeryresulting inmusculoskeletalimpairmentand/or pain,cognitiveimpairment andanxiety,
metabolicabnormalities(e.g., diabeticketoacidosis[DKA], uremia,or thyroiddysfunction),peritonitis, drugoverdose, and
breath sounds,
Assess respirations;note quality, rate,
pattern, depth, flaringof nostrils, dyspneaon exertion, evidenceof splinting, use ofaccessory muscles,and position for breathing.
Assess changes inmental status.
Assess changes invital signs andtemperature.
Decreased or absentbreath sounds These
may indicatepresence of mucusplug or other majorairway obstruction.
Wheezing These mayindicate increasingairway resistance.
Coarse sounds Thesemay indicatepresence of fluid
along larger airways.
Abnormality indicatesrespiratorycompromise.
Increasing lethargy,
confusion,restlessness, and/orirritability can be earlysigns of cerebralhypoxia.
Tachycardia andhypertension may berelated to increased
-
8/7/2019 Zamora - NCP
3/6
pleuralinflammation.
2. Performtherapeuticinterventionsto the patient
Assess cough for
effectiveness andproductivity.
Note presence ofsputum; assessquality, color,amount, odor, andconsistency.
Assess for pain
Assist patient inperforming coughingand breathingmaneuvers.
Use positioning (iftolerated, head of
work of breathing.Fever may develop inresponse to retainedsecretions/atelectasis.
Consider possiblecauses for ineffectivecough (e.g.,respiratory musclefatigue, severebronchospasm, orthick tenacioussecretions).
This may be a resultof infection,bronchitis, chronicsmoking, or othercondition. A sign ofinfection is discoloredsputum (no longerclear or white); anodor may be present.
Postoperative paincan result in shallow
breathing and anineffective cough.
These improveproductivity of thecough.
-
8/7/2019 Zamora - NCP
4/6
3. Conducthealthteaching withthe mother.
bed at 45 degrees;sitting in chair,ambulation).
Administermedications (e.g.,antibiotics, mucolyticagents,bronchodilators,expectorants) asordered, notingeffectiveness andside effects.
Instruct mother in thefollowing:
Optimalpositioning(sittingposition)
Use of pillowor handsplints whencoughing
Use of abdominalmuscles formore forcefulcough
Use of quadand huff techniques
These promote betterlung expansion andimproved airexchange.
Directed coughingtechniques helpmobilize secretionsfrom smaller airwaysto larger airwaysbecause the coughingis done at varyingtimes. The sittingposition and splintingthe abdomen promotemore effectivecoughing byincreasing abdominalpressure and upward
-
8/7/2019 Zamora - NCP
5/6
4. Provideteachingregardingthings torememberonce theclient is
discharge.
Use of incentivespirometry
Importanceofambulationand frequentpositionchanges
Encourageoral intake offluids within
the limits ofcardiacreserve
Tell to the mother theff:
Demonstrate andteach coughing,
deep breathing,and splintingtechniques.
Explain effects of
diaphragmaticmovement.
Increased fluid intakereduces the viscosity
of mucus produced bythe goblet cells in theairways. It is easierfor the patient tomobilize thinnersecretions withcoughing.
Patient willunderstand therationale andappropriatetechniques to keepthe airway clear ofsecretions.
-
8/7/2019 Zamora - NCP
6/6
smoking, includingsecond-hand smoke.
Instruct onindications for,frequency, and sideeffects of medications
Instruct how to useprescribed inhalers,as appropriate.
In home sett ing,instruct regardingcough enhancementtechniques and needfor humidification.
Teach aboutenvironmentalfactors that canprecipitaterespiratory problems.
Smoking contributesto bronchospasm andincreased mucusproduction in theairways.
top related