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NCP

NCP

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Published by Mua Amier

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Published by: Mua Amier on Feb 15, 2011
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01/30/2013

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NURSING CARE PLAN
Problem: HypoxiaNursing Diagnosis: Impaired gas exchange related to altered oxygen carrying capacity of bloodCause Analysis: Impaired gas exchange results from the destruction of the walls of overdistended alveoli. As the walls of alveoli are destroyed, the alveolar surfacearea in direct contact with pulmonary capillary continually decreases, causing an increase in dead space and impaired oxygen diffusion, which leads to hypoxemia( Medical-surgical Nursing by Smeltzer page 570).CUES OBJECTIVES INTERVENTIONS RATIONALEEVALUATIONSubjective:““Nahihirapan akong huminga kungwalang oxygen,as verbalized by thepatient.Objectives:
Irritable
Tachypneic
Difficulty of vocalizing
BP-100/60 mmhg
PR – 114 bpm
RR – 48 bpm
O2 saturation – 80%STO:Within 3 days of nursing care,The patient will be able toExperience increased pulmo-nary ventilation and adequateGas exchange as evidenced byIncreased oxygen saturationand normal respiratory rate.INDEPENDENTAuscultated lung sounds, monitor v/s.Positioned client inhigh Fowler’sposition.Instructed and encourage the client indeep breathing and effective coughingexercises.Provided calm, quiet environment.Limit pt’s activity or encourageBed rest.COLLABORATIVEMonitored pulse Oximetry.Administered O2 inhalation @ 9LPMVia face maskAdministered Berodual 1 neb q 8H,Salbutamol 1 neb q 4H & Flixotide 1neb q 12HThis allows evaluation of effects of Therapy.This maximizes pulmonary ventilationThese techniques improve ventilationBy opening airways to facilitateClearing the airways of sputum. Gas Exchange improvedand fatigue is Reduced.This minimizes shortness of breathAnd Fatigue.Useful tool to detect changes inoxygenation early onAppropriate amount of oxygen iscontinuously delivered so that the patient does notdesaturateA bronchodilator is a substance thatdilates the bronchi andbronchioles, decreasingresistance in the respiratory airwayand increasing airflow to the lungsSTO:After 3 days of nursingCare, the goal waspartially met with an O2saturation of 92% and anRR of 25bpm.
 
NURSING CARE PLAN
Problem: Risk for InjuryNursing diagnosis: Risk for injury related to generalized muscle weakness and edema on lower extremitiesCause Analysis: Weak leg muscles, weak knees, poor balance and loss for flexibility may contribute to falls and may have increase risk for injury.(Reference: Fundamentals of Nursing by Kozier pp. 118 – 119)
CUES OBJECTIVES NURSING INTERVENTIONS RATIONALES EVALUATIO
SUBJECTIVE
:Hindi ko nanaalagaan ang sariliko dahil nanghihina naang katawan ko,asverbalized by thepatient.
OBJECTIVE
:
(+) wheezes
appears weak& drowsy
Tachypnea
RR- 48 bpm
Irritability
Sputum color of yellowish &slightly sticky
Bilateral pittingedema grade 3
Distendedabdomen withabdominalgirth of 88cm
STO:
After 3 days of nursinginterventions the pt will beable:- to achieve measurableincrease in activitytolerance.- to reduced fatigue &weakness.
INDEPENDENT
:1. Promoted bed rest/chair (recliner)rest during toxic state.2. Provided quiet environment; limitvisitors.3. Do necessary task quietly & at onetime as tolerated.4. Recommend changing positionfrequently. Provider/instant caregiver in good skin care.5. Increased activity as tolerated,demonstrated passive ROMexercise.
COLLABORATIVE
:.Monitored pulse Oximetry.Administered O2 inhalation @ 9LPM
Via face mask 
1 Available energy use for healing.Activity & an upright position arebelieved to decrease hepatic bloodflow, w/c prevents optimal circulationto the liver cells.2. Allows for extended periods of uninterrupted rest.3. Promotes optimal respiratory fxn &minimizes pressure areas to reducerisk of tissue breakdown.4. Prolonged bed rest can bedeliberating. This can be offset bylimited activity5. Promotes rest and relaxation..Useful tool to detect changes inoxygenation early onAppropriate amount of oxygen iscontinuously delivered so that the patient does notdesaturate
STO
:After 3 days of nursinginterventions, the goal wasn’tmet. the pt will wasn’t able toachieve measurable increase inactivity tolerance & wasn’t toreduce fatigue & weakness.
 
 
NURSING CARE PLANS
Problem: Loss of appetiteNursing Diagnosis: Imbalanced Nutrition: Less than Body Requirements r/t malnutrition 2t Miliary TBCause Analysis: Malnutrition is a symptom that presents as a complex disorder with many possible differential diagnoses. A decreased appetite andan unwillingness to eat are characteristics of the symptom. The symptoms of malnutrition and weight loss, in addition to hemoptysis, chills, fever andnight sweats are important pathologic clues to a diagnosis of TB. (individualbraids.gq.nu/anorexia
 
)
CUES OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATIONSUBJECTIVE
:“Parang wala siyanggana kumain, kasikonteng konte lang angna uubos niya,asverbalized by the SO.
OBJECTIVE
:
Observable wt.loss
Dry, pale lips
Appears weak &drowsy
Dry & crackedlips, slightly palemucosa
occasionalproductive cough,yellowish andslightly stickysputum
minimal foodintake
tachypneic
(+) Miliary TB
STO
:After 3 days of nursingintervention, the client wilverbalize & demonstrateselection of foods or mealsthat will achieve a cessationof wt. loss.
INDEPENDENT
:
Documented client’snutritional status onadmission, noting skinturgor, current weight anddegree of weight loss,integrity of oral mucosa,ability or inability to swallowpresence of bowel tones,and history of nausea andvomiting or diarrhea.
Monitored I&O
Investigated anorexia andnausea/ vomiting, and notepossible correlation tomedications. Monitoredfrequency, volume, andconsistency of stools.
Encouraged and providedfor frequent rest periods.
Encouraged small, frequentmeals with foods high inprotein and carbohydrates.
Useful in defining degreeor extent of problem andappropriate choice of interventions.
Useful in measuringeffectiveness of nutritionaland fluid support.
May affect dietary choicesand identify areas foproblem solving toenhance intake/ utilizationof nutrients.
Helps conserve energy,especially when metabolicrequirements areincreased by fever.
Maximizes nutrient intakewithout undue fatigue or energy expenditure fromeating large meals, andreduces gastric irritation.
Creates a more normal
STO
:After 3 days of nursingintervention, the was notmet, the client wasn’t able todemonstrate selection of foods or meals that willachieve a cessation of wt.loss.

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