Cues Subjective: Objective: y Inability to expectorate phlegm by coughing y Presence of lung crackles y Snoring
Nursing Diagnosis Ineffective airway clearance related to blockage of respiratory tracts as evidenced by presence of crackles and snoring.
Inference Mucus production
Plan of Care
Evaluation After 30 minutes of nursing intervention, goal was fully met as manifested by: a.) Decreased crackles b.) decreased amount of mucus in the respiratory tract
Within 30 minutes of nursing intervention, the Prolonged bed rest patient will be able to demonstrate Retained mucus improved secretion (presence breathing as of crackles) manifested by: a.) decrease of crackles b.) decrease amount of mucus in the respiratory tract (observed through suctioning)
1. Assist the patient 1. To promote into high-fowler¶s maximal lung position expansion. 2. Check the 2. To assess the patient¶s skin color. degree of O2 deprivation. 3. Suction the patient¶s mouth 3. To and nose as mechanically needed. remove the mucus present in the upper respiratory tract. 4. Give mucolytic agent as ordered. 5. To loosen up mucus at the 5. Nebulize the respiratory tract. patient as ordered. 6. To promote 6. Administer O2 bronchodilation. therapy as ordered. 6. To achieve O2 demand by the body.
Pooling of mucus in the respiratory tract
Cues Subjective: Objective: y Lack of energy y Difficulty staying asleep
Nursing Diagnosis Disturbed sleep pattern related to presence of environmental factors as evidenced by lack of energy and difficulty staying asleep.
Inference Interruptions of sleep for medical/ nursing intervention
Plan of Care Within 8 hours of nursing intervention, the patient will attain optimal time of sleep as manifested by: a.) increase in number of hours of uninterrupted sleep b.) increase sense of well being
Intervention 1. Assess for factors that contribute to the patient¶s lack of sleep. Change the modifiable factors. 2. Group the interventions that necessitate waking of the patient and perform it at the same time if it permits. 3. Render nursing interventions without waking the patient whenever possible. 4. Apply measures that will make the patient comfortable (giving a bath, changing linens etc.) 5. Apply appropriate
Rationale 1. To lessen the factors that contributes to disruption of patient¶s sleep. 2. To eliminate unnecessary waking of the patient.
Evaluation After 8 hours of continuous nursing intervention, the goal was partially met as manifested by:
Exposure to light
Exposure to noise made by machines
Lack of sleep
a.) increased in number of 3. To promote hours of optimum number uninterrupted of hours of sleep sleep. of the patient. b.) sense of 4. To make the well being patient relaxed, still at low thus making level them easier to get to sleep. 5. To eliminate the need of the patient to go to the bathroom.
alternative toileting method (catheter for urination and diapers for defecation).
Cues Subjective: Objective: y At complete bed rest y Slow movements y Observed weakness
Nursing Diagnosis Self care deficit related to neuromuscular impairment as evidenced by weakness.
Inference Cerebrovascular disease
Plan of Care Within 3 hours of nursing intervention, the patient will be able to attain self care needs dependently as manifested by:
Intervention 1. Administer feeding via NGT tube as ordered. 2. Place catheter for urination and diapers for defecation.
Evaluation After 3 hours of nursing intervention, the goal was completely met as manifested by: a.) appropriate alternative feeding method b.) appropriate alternative toileting method c.) improved hygiene and grooming
Inability to perform self care
a.) appropriate 3. Render oral care alternative feeding to the patient. method 4. Render bed bath b.) appropriate to the patient. alternative toileting method 5. Change the clothing of the c.) improved patient regularly. hygiene and grooming