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NCP NeuroICU

NCP NeuroICU

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Published by Karl Masangcay

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Categories:Types, School Work
Published by: Karl Masangcay on Nov 06, 2010
Copyright:Attribution Non-commercial

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05/12/2014

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Cues
Nursing
Diagnosis
Inference
Plan of Care
Intervention
Rationale
Evaluation
Subjective:
Objective:
yInability to
expectorate
phlegm by
coughing
yPresence of
lung
crackles
ySnoring
Ineffective
airway clearance
related to
blockage of
respiratory tracts
as evidenced by
presence of
crackles and
snoring.
Mucus production
Prolonged bed rest
Retained mucus
secretion (presence
of crackles)
Ineffective cough
Pooling of mucus
in the respiratory
tract
Snoring
Within 30 minutes
of nursing
intervention, the
patient will be
able to
demonstrate
improved
breathing as
manifested by:
a.) decrease of
crackles
b.) decrease
amount of mucus
in the respiratory
tract (observed
through
suctioning)
1. Assist the patient
into high-fowler¶s
position
2. Check the
patient¶s skin color.
3.Suction the
patient¶s mouth
and nose as
needed.
4. Give mucolytic
agent as ordered.
5. Nebulize the
patient as ordered.
6. Administer O2
therapy as ordered.
1. To promote
maximal lung
expansion.
2. To assess the
degree of O2
deprivation.
3. To
mechanically
remove the
mucus present in
the upper
respiratory tract.
5. To loosen up
mucus at the
respiratory tract.
6. To promote
bronchodilation.
6. To achieve O2
demand by the
body.
After 30
minutes of
nursing
intervention,
goal was fully
met as
manifested by:
a.) Decreased
crackles
b.) decreased
amount of
mucus in the
respiratory
tract
Cues
Nursing
Diagnosis
Inference
Plan of Care
Intervention
Rationale
Evaluation
Subjective:
Objective:
y Lack of
energy
y D iff icu lt y
staying
asleep
Disturbed sleep
pattern related to
presence of
environmental
factors as
evidenced by
lack of energy
and difficulty
staying asleep.
Interruptions of
sleep for medical/
nursing
intervention
Exposure to light
Exposure to noise
made by machines
Lack of sleep
Within 8 hours of
nursing
intervention, the
patient will attain
optimal time of
sleep as
manifested by:
a.) increase in
number of hours
of uninterrupted
sleep
b.) increase sense
of well being
1. Assess for
factors that
contribute to the
patient¶s lack of
sleep. Change the
modifiable factors.
2. Group the
interventions that
necessitate waking
of the patient and
perform it at the
same time if it
permits.
3. Render nursing
interventions
without waking the
patient whenever
possible.
4. Apply measures
that will make the
patient comfortable
(giving a bath,
changing linens
etc.)
5. Apply
appropriate
1. To lessen the
factors that
contributes to
disruption of
patient¶s sleep.
2. To eliminate
unnecessary
waking of the
patient.
3. To promote
optimum number
of hours of sleep
of the patient.
4. To make the
patient relaxed,
thus making
them easier to
get to sleep.
5. To eliminate
the need of the
patient to go to
the bathroom.
After 8 hours
of continuous
nursing
intervention,
the goal was
partially met
as manifested
by:
a.) increased
in number of
hours of
uninterrupted
sleep.
b.) sense of
well being
still at low
level
alternative toileting
method (catheter
for urination and
diapers for
defecation).

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