Nursing Care Plan

Ineffective airway clearance Cues Nursing Diagnosis I- “nahihirapan Ineffective ako huminga airway at kapag clearance umuubo ako related to may asthma as a kasamang manifested by plema” as difficulty of verbalized by breathing. the patient. O- Difficulty & rapidly in breathing. M- RR-23 bpm BP-100/70 PR-82 bpm T- 37.3 Planning After nursing intervention the patient will able to Objectives: manage and maintain airway patency. After 2hrs. nursing intervention the patient will: a. Verbalize understandin g of causes & therapeutic management regimen within 20mins. b. Demonstrate behavior to improve & maintain clear airway within 30mins. c. Demonstrate reduction of congestion w/ breath sounds clear Intervention To maintain adequate patient airway the nurse will able: a. monitor respiration & breath sound, noting rate & sounds (e.g. tachypnea, crackles, wheezes.) b. Elevate head of bed/change position every 2hrs. prn. Rationale Evaluation Goes met the client able to maintain airway clearance and clear secretions readily.

Indicative of respiratory distress or accumulation of secretion.

c. Keep environment allergen free (e.g.broncho scopy tracheotomy To clear/ ) maintain open

To take advantage of gravity decreasing, pressure on the diaphragm & enhancing drainage of ventilation to diff. lung segment.

respiration noiseless improved oxygen exchange within 30mins. d. Identify potential complication on how to initiate appropriate preventive or corrective actions within 20mins.

d. To mobilize secretion  encourage deep breathing & coughing exercise splint chest/incisio n.  Dependent; administer analgesic  Give expectorant s or bronchodilat ors as ordered.  To promote wellness; demonstrate client in performing specific airway clearance technique.

airway.

To maximize effort.

To improve cough when pain is inhibiting effort.

Cues

Nursing Diagnosis

Planning or Goal

Nursing Intervention

Rationale

Evaluation

I: “My incision site is so painful” as verbalize by the patient. O: Presence of facial grimace when palpation the abdominal area and guarding the area when assessing it. M: •BP- 100/70 mmhg •T- 37.3°C •PR- 89 bpm •RR- 19 •Pain scale5/10

•Acute pain related to physical factor e.g., disruption of skin & tissue (incision) as evidence by reports of pain and guarding at the area.

•After 2 hrs nursing intervention the patient will: •Decrease pain rate from 5 to 2 •Report pain is relieved/controlled.

•Use pain rating scale appropriate for age/cognition •Observe nonverbal cues/pain behaviors.

•To evaluate patient response to pain. •Observations may/may not be congruent with verbal reports or may be only indicator present when patient is unable to verbalize. •To prevent fatigue.

•Goals partially met. The patient able to control and reduce pain. •From pain rate of 5 decrease to 3.

•Encourage adequate rest periods.

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