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NCP Difficulty of Breathing r/t Secretion

NCP Difficulty of Breathing r/t Secretion

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Published by: herscentasiascribd on Jul 28, 2010
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07/15/2013

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NURSING CARE PLAN
Name of Patient:Age: 65 y/oCivil Status:Nationality:Occupation:Date of Admission:Chief Complaint/ Diagnosis: Difficulty of breathingSex: Male
CUESPROBLEM/ HEADNURSINGDIAGNOSISSCIENTIFICEXPLANATIONNURSINGOBJECTIVENURSINGINTERVENTIONSCIENTIFICEXPLANATIONEVALUATION
 
Subjective:“Sumasakit ang dibdibko kapag humihinga”as verbalized by thepatient.Objective:
Dyspnea
Nasal flaring
Distended neckvein
Wheezing
Chest pain
Rapid and shallowbreathing
V/S taken asfollows:RR: 32 breaths/minPR: 80
XRAY (4/06/10) –
Result:
Fluffybasal densities arepresent
Impression:
Pneumonia and/or edemaDifficulty of breathingrelated to presence of phlegm on thetracheobronchial treeAmong the mostcommon symptomsof lung disorders arecough, dyspnea, andwheezing. Lesscommonly, ablockage in theairways between themouth and lungsresults in a gaspingsound whenbreathing. Problemsin the lungs can alsolead to coughing upof blood or hemoptysis, a bluishdiscoloration of theskin due to a lack of oxygen in the blood,or chest pain.After 2 days of nursinginterventions, thepatient’s respirationshall have improvedand difficulty of breathing shall havebeen relieved.
monitored respiratorypatterns including rate,depth, and effort
Auscultated breathsounds notingdecreased or absentsounds, crackles, or wheezing.
positioned the client tooptimize respiration
encouraged patient toperform deepbreathing
encouragedambulation astolerated withoutcausing exhaustion
With secretion in theairway, the respirationrate will increase.
These abnormal lungsounds can indicatepathology associatedwith an alteredbreathing pattern.
An upright positionallows maximal lungexpansion while lyingflat on bed causesabdominal organs toshift toward the chest,which crowds the lungsand makes it moredifficult to breath.
This technique canhelp increase sputumclearance anddecrease coughspasm.
Immobility is oftenharmful to the elderlybecause it decreasesventilation andincreases stasis of secretions, leading toatelectasis or pneumonia.After 2 days of nursing intervention,the patient respirationhas been improvedand difficulty of breathing has beenrelieved asevidenced by:
(-) dyspnea
(-) nasal flaring
(-) distended neckvein
(-) wheezing
RR: 25 breaths/minNursing objectivewas met.

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