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  • Nursing Care Plan NO1

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    Ryan Mulano
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    The mother reported the patient was having difficulty breathing and constantly vomiting phlegm. On examination, the patient had sputum production, rapid and shallow breathing, and crackles upon auscultation. The diagnosis was ineffective airway clearance due to the patient's inability to keep their airway clear, as shown by positive sputum, crackles, and rapid shallow breathing. The plan was to monitor the patient and perform airway clearance treatments for 8 hours, after which there should be no crackles or gargling sounds upon listening to the lungs.

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    The mother reported the patient was having difficulty breathing and constantly vomiting phlegm. On examination, the patient had sputum production, rapid and shallow breathing, and crackles upon auscultation. The diagnosis was ineffective airway clearance due to the patient's inability to keep their airway clear, as shown by positive sputum, crackles, and rapid shallow breathing. The plan was to monitor the patient and perform airway clearance treatments for 8 hours, after which there should be no crackles or gargling sounds upon listening to the lungs.

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    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
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    7 views1 page

    Nursing Care Plan NO1

    Uploaded by

    Ryan Mulano
    The mother reported the patient was having difficulty breathing and constantly vomiting phlegm. On examination, the patient had sputum production, rapid and shallow breathing, and crackles upon auscultation. The diagnosis was ineffective airway clearance due to the patient's inability to keep their airway clear, as shown by positive sputum, crackles, and rapid shallow breathing. The plan was to monitor the patient and perform airway clearance treatments for 8 hours, after which there should be no crackles or gargling sounds upon listening to the lungs.

    Copyright:

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    of 1

    Assessment Subjective: Nahihirapan siyang huminga saka lagi na lang sumusuka ng plema, as verbalized by the mother.

    Objective: (+) sputum production Rapid, shallow breathing (+) crackles, Gargles Vital sign Taken PR: RR: TEMP:

    Diagnosis Ineffective Airway Clearance related to inability to maintain clear airway as characterized by (+) sputum, (+) crackles, rapid & shallow breathing

    Planning After 8 hours of Nursing Intervention, the Pts breathing will have no more adventitious sounds present (crackles/gargles) when auscultated

    Implementation Monitor respiratory patterns, Including rate, depth, and effort. Assist with clearing secretions from pharynx by offering tissues and gentle suction of the oral pharynx if necessary Provide postural drainage, percussion, and vibration as ordered Administer medications such as bronchodilators or inhaled steroids as ordered.

    Rationale

    Evaluation After 8 hours of Nursing Intervention, the Pts breathing had no more adventitious sounds (crackles/gargles) present when auscultated

    With secretions in the airway, the respiratory rate will increase It is preferable for the client to cough up secretions. Gentle suctioning of the posterior pharynx may Stimulate coughing and help remove secretions. Chest physical therapy helps mobilize bronchial secretions Bronchodilators decrease airway resistance secondary to bronchoconstriction

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