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NCP - Osteosarcoma

NCP - Osteosarcoma

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Published by Nelson Lacsamana

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Categories:Types, School Work
Published by: Nelson Lacsamana on Aug 24, 2011
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03/28/2013

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Palomo, Axcel Dean G.BSN 219Cues Analysis NursingDiagnosisGoals andObjectivesNursingInterventionRationale EvaluationS- the clients mother verbalizeddumadalasnasiyanginuubo atsinisiponkasabayngpananakitngtiyanniya.O- the client has productive cough withyellow colored secretionsThe client has clear discharge on his nose.Presence of crackles on chest uponauscultation.Therespiratorysystemprovides gasexchange bymeans of ventilation,oxygentransportand tissueperfusion;helpsmaintainacid-basebalance andserve as animmunedefense. Apatienthavingineffectiveairwayclearancehas aninability toclearsecretionsorIneffectiveairwayclearancerelated toretainedsecretionsasmanifestedbyproductivecough andadventitiousbreathsoundsGoal:After 8 hoursof nursinginterventionthe client willhave aneffectiveairwayObjectives:After 5minutes of discussingtheimportanceof therapeuticmanagementto theclientsmother, theclientsmotherwould beable to give 5The nurse willdiscuss 5 out 5importance of therapeuticmanagementThe nurse willencourage theProvidinginformation onclient promotestrust andcooperation of the patient to thenurseDeep breathingexcersise andWas the clientbe able todiscuss 5 out5 importanceof therapeuticmanagement?Yes:No:Why:Was the client
 
obstructionsfrom therespiratorytract tomaintainclear airway.If nottreated, thismight causea seriousrespiratoryproblem.Nanda11
th
ed, p77-81Lippincott:Medical-SurgicalNursing.out 5importanceof therapeuticmanagementAfter 10minutes of nursingintervention,the clientwould beable toexpectoratesecretionsreadily.client toperform thedeep breathingexcersise andcoughingexerciseThe nurse willbe able to giveexpectorantsandbronchodilatorsas ordered bythe physicianThe nurse willencourage theclient toincrease fluidintakeThe nurse willperform andassist the clientfor posturaldrainage andchest-physiotherapyThe nurse willbe able toassess and noteclientscoughing exercisepromote maximalmucous drainageExpectorantsassists in mucousexpulsion andbronchodilatorspromotes easyrespirationHydration canhelp liquifyviscous secretionsand improveairway clearancePostural drainageand chest-physiotherapy helps toremove mucousin the bronchiolesNoting clientsresponse totreatment willhelp the nurseassess forprogressbe able toexpectoratesecretions?Yes:No:Why:Was the clientbe able todemonstratereduction of congestionswith breathsounds clear
 
 After 30minutes of nursingintervention,the clientwould beable todemonstratereduction of congestionswith breathsounds clearandrespirationnoiselessAfter 45minutes of nursingintervention,the client willbe able tomaintainpatentairwayresponse totreatmentThe nurse willauscultatebreath soundsand assess airmovementsThe nurse willmonitorrespiration andbreath soundsnoting rate andsoundsThe nurse willposition headappropriate forage andconditionThe nurse willelevate head of bed or changeclients positionevery 2 hoursAuscultating andassessing airmovementascertain statusand noteprogress.It is indicative of respiratorydistress oraccumulation of mucous secretionPositioning thehead of the clientappropriatelymaintain openairway in at restor compromisedindividualElevating thehead of the bedor changing theposition of theclient takeadvantage of gravity decreasingpressure on thediaphgram andenhancingdrainageof/ventilation of andrespirationnoiseless?Yes:No:Why:Was the clientbe able tomaintainpatentairway?Yes:No:Why:

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