NURSING CARE PLAN Problem: Hypoxia Nursing Diagnosis: Impaired gas exchange related to altered oxygen carrying capacity
of blood Cause Analysis: Impaired gas exchange results from the destruction of the walls of overdistended alveoli. As the walls of alveoli are destroyed, the alveolar surface area in direct contact with pulmonary capillary continually decreases, causing an increase in dead space and impaired oxygen diffusion, which leads to hypoxemia ( Medical-surgical Nursing by Smeltzer page 570). CUES Subjective: OBJECTIVES STO: Within 3 days of nursing care, ““Nahihirapan akong huminga kung The patient will be able to walang oxygen,” as verbalized by the Experience increased pulmopatient. nary ventilation and adequate Gas exchange as evidenced by Increased oxygen saturation Objectives: and normal respiratory rate. Irritable Tachypneic Difficulty of vocalizing BP-100/60 mmhg PR – 114 bpm RR – 48 bpm O2 saturation – 80% INTERVENTIONS INDEPENDENT Auscultated lung sounds, monitor v/s. Positioned client inhigh Fowler’s position. Instructed and encourage the client in deep breathing and effective coughing exercises. Provided calm, quiet environment. Limit pt’s activity or encourage Bed rest. COLLABORATIVE Monitored pulse Oximetry. Administered O2 inhalation @ 9LPM Via face mask Administered Berodual 1 neb q 8H, Salbutamol 1 neb q 4H & Flixotide 1 neb q 12H EVALUATION STO: This allows evaluation of effects of After 3 days of nursing Therapy. Care, the goal was partially met with an O2 This maximizes pulmonary ventilation saturation of 92% and an RR of 25bpm. These techniques improve ventilation By opening airways to facilitate Clearing the airways of sputum. Gas Exchange improved and fatigue is Reduced. This minimizes shortness of breath And Fatigue. RATIONALE
Useful tool to detect changes in oxygenation early on Appropriate amount of oxygen is continuously delivered so that the patient does not desaturate A bronchodilator is a substance that dilates the bronchi and bronchioles, decreasing resistance in the respiratory airway and increasing airflow to the lungs
NURSING CARE PLAN Problem: Risk for Injury Nursing diagnosis: Risk for injury related to generalized muscle weakness and edema on lower extremities Cause Analysis: Weak leg muscles, weak knees, poor balance and loss for flexibility may contribute to falls and may have increase risk for injury. (Reference: Fundamentals of Nursing by Kozier pp. 118 – 119) CUES OBJECTIVES NURSING INTERVENTIONS RATIONALES SUBJECTIVE: STO: INDEPENDENT: STO: “Hindi ko na naalagaan ang sarili ko dahil nanghihina na ang katawan ko,” as verbalized by the patient. After 3 days of nursing interventions the pt will be able: - to achieve measurable increase in activity tolerance. - to reduced fatigue & weakness. 1. Promoted bed rest/chair (recliner) rest during toxic state. 1 Available energy use for healing. Activity & an upright position are believed to decrease hepatic blood flow, w/c prevents optimal circulation to the liver cells. 2. Allows for extended periods of uninterrupted rest. 3. Promotes optimal respiratory fxn & minimizes pressure areas to reduce risk of tissue breakdown. 4. Prolonged bed rest can be deliberating. This can be offset by limited activity 5. Promotes rest and relaxation..
After 3 days of nursing interventions, the goal wasn’t met. the pt will wasn’t able to achieve measurable increase in activity tolerance & wasn’t to reduce fatigue & weakness.
2. Provided quiet environment; limit visitors. 3. Do necessary task quietly & at one time as tolerated. 4. Recommend changing position frequently. Provider/instant caregiver in good skin care. 5. Increased activity as tolerated, demonstrated passive ROM exercise.
OBJECTIVE: • • • • • • • • (+) wheezes appears weak & drowsy Tachypnea RR- 48 bpm Irritability Sputum color of yellowish & slightly sticky Bilateral pitting edema grade 3 Distended abdomen with abdominal girth of 88cm
COLLABORATIVE:. Monitored pulse Oximetry. Administered O2 inhalation @ 9LPM Useful tool to detect changes in oxygenation early on Appropriate amount of oxygen is continuously delivered so that the patient does not desaturate
Via face mask
NURSING CARE PLANS Problem: Loss of appetite Nursing Diagnosis: Imbalanced Nutrition: Less than Body Requirements r/t malnutrition 2t Miliary TB Cause Analysis: Malnutrition is a symptom that presents as a complex disorder with many possible differential diagnoses. A decreased appetite and an unwillingness to eat are characteristics of the symptom. The symptoms of malnutrition and weight loss, in addition to hemoptysis, chills, fever and night sweats are important pathologic clues to a diagnosis of TB. (individualbraids.gq.nu/anorexia) CUES OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION SUBJECTIVE: STO: INDEPENDENT: STO: • Useful in defining degree Documented client’s “Parang wala siyang After 3 days of nursing or extent of problem and After 3 days of nursing nutritional status on gana kumain, kasi intervention, the client wil appropriate choice of intervention, the was not admission, noting skin konteng konte lang ang verbalize & demonstrate met, the client wasn’t able to interventions. turgor, current weight and na uubos niya,” as selection of foods or meals demonstrate selection of degree of weight loss, verbalized by the SO. that will achieve a cessation foods or meals that will integrity of oral mucosa, of wt. loss. achieve a cessation of wt. ability or inability to swallow loss. presence of bowel tones, OBJECTIVE: and history of nausea and vomiting or diarrhea. • Observable wt. • Useful in measuring Monitored I&O loss effectiveness of nutritional • Dry, pale lips and fluid support. • Appears weak & • May affect dietary choices Investigated anorexia and drowsy and identify areas for nausea/ vomiting, and note problem solving to • Dry & cracked possible correlation to enhance intake/ utilization lips, slightly pale medications. Monitored of nutrients. mucosa frequency, volume, and • occasional consistency of stools. • Helps conserve energy, productive cough, Encouraged and provided especially when metabolic yellowish and for frequent rest periods. requirements are slightly sticky increased by fever. sputum • Maximizes nutrient intake • minimal food Encouraged small, frequent without undue fatigue or intake meals with foods high in energy expenditure from • tachypneic protein and carbohydrates eating large meals, and • (+) Miliary TB reduces gastric irritation. • Creates a more normal .
Encouraged SO to bring
foods from home and to share meals with client unless contraindicated. COLLABORATIVE: • Refered to the dietitian for adjustments in dietary composition. •
social environment during mealtime, and helps meet personal and cultural preferences. Provides assistance in planning a diet with nutrients adequate to meet client’s metabolic requirements, dietary preferences, and financial resources post/ discharge.