zamora - ncp

8/7/2019 Zamora - NCP

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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.


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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


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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.


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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


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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.


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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.

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