XI.

Nursing Care Plan Assessment Nursing Diagnosis Rationale Desired Outcome Intervention Justification Evaluation

Actual Abnormal Cues: Patient stated that, ga-lain matyag ko kg indi ko maayo ka ginhawa. Appears tired and weak Shortness of breath Productive cough with whitish phlegm Chest pain Lung crackles Strengths: Good compliance to medical and

Ineffective airway clearance related to increased sputum production as evidenced by dyspnesa, abnormal breath sounds, ineffective cough with sputum production

Lung cancer

After 8 hours of nursing care, the client will be able to: 1. Maintain airway patency

Independent:

After 8 hours of nursing care, the client was able to: To open or maintain open airway in at rest or compromised individual To take advantage of the gravity decreasing pressure on diaphragm and enhancing drainage of/ ventilation to different lung segments

Tumor in the airways

Obstruction of passageway of air Accumulation of secretions behind the blockage

Position head midline with flexion appropriate for age/ condition Elevate head of the bed/ change position every 2 hours and prn

Source: Nurses Pocket Guide Diagnoses, Prioritized Interventions, and Rationales, Edition

Breathing difficulties

Ineffective airway clearance

nursing interventions Positive attitude towards recovery Strong family support system

11 Doenges Moorhouse Murr

2. Expectorate/ clear secretions daily

Increase fluid intake to at least 2000 ml/day within level of cardiac tolerance Encourage/ provide warm versus cold liquids as appropriate

Hydration can help liquefy viscous secretions

Ambivent Risk Factors: Old age (63 y.o) History of being a heavy smoker Works as a painter Family history of Lung Cancer (father) 3. Demonstrate behaviors to improve/ maintain clear patency

To prevent hardening of secretions

Perform/ assist client with postural drainage

To take advantage of gravity and enhance drainage of secretions To improve lung function

Support reduction/ cessation of smoking