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NURSING CARE PLAN CUES NURSING DIAGNOSIS P>Ineffective Airway Clearance SCIENTIFIC BACKGROUND Bacterial microorganism enter the airways OBJECTIVE NURSING INTERVENTIONS RATIONALIZATION EVALUATION Date: April 24, 2012 Time: 6:30 AM
SUBJECTIVE: > May halak siya at nahihirapan ding huminga, as verbalized by the watcher. OBJECTIVES: >With O2 support via face mask at 5LPM >Weak in appearance >irritable >presence of dyspnea as evidenced by RR 83 cpm >(+) crackles heard upon auscultation on both lungs >(+) DOB noted >cried at times >v/s taken as follows: Temp: 37.8 C, RR: 83cpm, PR: 130bpm, O2 sat: 85
Date: April 24, 2012 Time: 6:00AM Within 30 min of rendering nursing interventions, the patient will maintain airway patency, expectorate/ clear secretions readily and demonstrate absence/ reduction of congestion with breath sounds clear, respirations noiseless, improved O2 exchange (absence of cyanosis, O2 sat results within client norms) Objectives: >With no O2 support >fair looking
E>related to inability to maintain clear airway as characterized by presesnce of dyspnea, (+) crackles, (+) DOB noted.
INDEPENDENT: Monitor v/s of the To assess changes, have patient especially RR a baseline data and note and pulse complication Goal: Goal partially met Auscultate breath To ascertain status and sounds and assess air note progress Evidences: movement >still with O2 support via Face Observe sx of To assess for any mask at 5LPM respiratory changes and note >fair-looking distress(inc. RR, complication >not irritated restlessness, use of >absence of dyspnea accessory muscles in as evidenced by RR breathing, capilliary of 60cpm refill) > decrease crackles heard upon Elevate the head of To take advantage of auscultation on both the bed into semi gravity and dec. lungs fowlers and change pressure on the >(-) DOB noted position every 2 hrs. diaphragm enhancing >O2 sat of 93% drainage to different >v/s taken as lung segments. follows: Temp 36.8 C,RR: Increase fluid intake 60cpm, PR: 125bpm within level of To help liquefy tolerance. secretions
>absence of dyspnea, RR will be within Normal range >(-) crackles auscultated on both lungs >(-) DOB noted
CPT every after nebulization Maintain a wellventilated and quiet envt. DEPENDENT: Administer analgesicsparacetamol 1251 supp sup Q4 Administer salbutamol neb +2ml PNSS Q6
To hep loosen secretions and help expectorate secretions. Promote enough rest and promote wellness.
CUES
NURSING DIAGNOSIS P> Hyperthermia E> related to bacterial invasion in the lungs as manifested by body temperature higher than normal, skin
SUBJECTIVE > Nilalagnnat po sya mula kagabi, as verbalized by the watcher OBJECTIVES: >febrile @ 37.8 C
SCIENTIFIC BACKGROUND Bacterial microorganisms (e.g. pulmonary pathogens) enter the airway
OBJECTIVE
RATIONALIZATION
Date: April 24, 2012 Time: 6:00AM After 30 min of rendering nursing intervention, patients body
> To determine if the Pts temperature is above the normal body temperature > To maintain hydration status and
warm to touch. >Skin warm to touch >Weak in appearance >cried at times >v/s taken as follows: Temp: 37.8 C, RR: 83cpm, PR: 130bpm, O2 sat: 85 % These bacteria/viruses infects the lung/s
tolerance
Objectives: >Normal temp of 36-37.5C >Skin will cool off > fair looking > never cry
> Encourage the Pts guardian to do tepid sponge bath every fever episodes.
> Sponge bath with warm water evaporates off his skin, thus, cooling off the Pt
>Skin cool off > fair looking > never cry >v/s taken as follows: Temp 36.8 C,RR: 60cpm, PR: 125bpm
DEPENDENT: > Administer antipyretic medications as prescribed paracetamol 1251 supp sup Q4 > Promotes return of body temperature to normal
Signs and symptoms of Pneumonia (e.g.temperature may be greater than 37.5C), dyspnea, (+) crackles, (+) DOB
CUES
NURSING DIAGNOSIS
P> Impaired Gas SUBJECTIVE: >Nahihirapan syang Exchange huminga tapos nangitim pa sya, as E> r/t impaired verbalized by the oxygen demand and watcher supply as manifested by O2 support, weak in appearance, irritable, use of OBJECTIVE: >With O2 support accessory muscles via face mask at in breathing, 5LPM presence of >Weak in dyspnea, with Mucus production appearance crackles and DOB. Manifested by >irritable crackles >use of accessory muscles in breathing >presence of dyspnea as Bacteria invades evidenced by RR 83 alveolar cell in the cpm lungs >(+) crackles heard upon auscultation on both lungs >(+) DOB noted >capillary refill 1Impaired functioning 2sec of alveoli for gas >cried at times exchange
SCIENTIFIC OBJECTIVE BACKGROUND Pathological Entry (inhalation) of Date: April 24, 2012 organism: Bacteria or Time: 6:00 AM Viruses After an hour of nursing interventions, the patient will be able Occurrence of demonstrate localized improved ventilation inflammation and oxygenation of tissues. Objectives: >With no O2 support via face mask at 5LPM >fair-looking >not irritable >without the use of accessory muscles in breathing >no crackles heard upon auscultation >no DOB noted >never cry
NURSING RATIONALIZATION INTERVENTIONS INDEPENDENT: Monitor v/s of the patient especially RR and pulse.
EVALUATION
Date: April 24,2012 Time: 7:00 AM
Auscultate breath To ascertain status and sounds and assess air note progress movement. Note respiratory rate, depth; use of accessory muscles in breathing, capillary refill and cyanosis. Elevate the head of the bed /position the client appropriately. Provide adequate rest, sleep and limit activities to within tolerance. Keep the envt allergen/pollutant free. DEPENDENT: To evaluate degree of compromise
>With O2 support via face mask at 5LPM >fair-looking >not irritable >still with the use of accessory muscles in breathing in minimal >with crackles heard upon auscultation >no DOB noted >never cry >v/s taken as follows: Temp 36.8 C,RR: 60cpm, PR: 125bpm
>v/s taken as follows: Temp: 37.8 C, RR: 83cpm, PR: 130bpm, O2 sat: 85 Impaired Gas Exchange Brunner & Suddharts Textbook of Medical-Surgical Nursing 12th Edition
Administer medication as indicated, paracetamol 1251 supp sup Q4 (antipyretic), salbutamol neb +2ml PNSS Q6 (bronchodilator), ampicillin 185mg IV Q6 (antibiotic)
To facilitate breathing.