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NURSING CARE PLAN

ASSESSMENT Subjective Data: - No Subjective Data Objective Data:
The patient is on mechanical ventilator With crackles on both field of lungs upon auscultation Respiratory Rate of 28 Restlessness Irritabilty Facial Grimace

NURSING DIAGNOSIS
Ineffective Airway Clearance related to inability to remove airway secretions secondary to pulmonary tuberculosis

NURSING GOAL
At the end of 4 hours duty at the medical intensive care unit, the client’s secretions will be mobilized and minimized, as evidenced by decrease crackles in the lung sound, eupnea, and ability to effectively mobilize secretions.

INTERVENTIONS AND RATIONALE
1.) Monitor Vital Signs including respiratory rate and note for any respiratory distress Rationale: To obtain baseline vital signs for future comparison as well as to assess any signs and symptoms of respiratory distress 2.) Use positioning (if tolerated and not contraindicated, head of bed at 45 degrees)

Rationale: These promote better lung expansion and improved air exchange.
3.) Use humidity (humidified oxygen or humidifier at bedside).

Rationale: This loosens secretions.
4.) Standby suction machine and use soft tip rubbers catheters for suctioning

Rationale: These facilitate secretion removal.
5.) Stop suctioning and provide supplemental oxygen if the patient experiences

bradycardia, an increase in ventricular ectopy, and/or desaturation. Rationale: This prevents suction-related hypoxia.
6.) Reposition client every two hours

Rationale: To mobilize mucus secretions

decreased in respiratory rate. EVALUATION At the end of 4 hours duty and series of nursing interventions. and expectorant as prescribed by the physician Rationale: To kill bacteria. mucolytic. .) Administer antibiotics. secretions and expel mucus that blocks the airway. liquefy mucus. goals partially met as evidenced by gradual decreased of crackles in both lung fields upon auscultation.7.