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IDEAL NURSING CARE PLAN CUES Objectives:  Dyspnea  Abnormal breath sounds  Presence of discharges NURSING DIAGNOSIS Ineffective

airway clearance related to retained secondary to increased mucus production OBJECTIVES Short Term Objectives At the end of 30 minutes nursing intervention the patient will be able to  Maintain patent airway with breath sounds clear  Be free of aspirations  Loosen secretions Long Term Objectives At the end of 8 hours nursing intervention, the patient will be able to:  Demonstrate reduction of secretion and abnormal breath sounds.  SO will be able to demonstrate interventions as needed. NURSING INTERVENTIONS Independent 1.Assess airway patency RATIONALE  Obstruction may caused by accumulation of secretions or problem with the placement of ET tube  Symmetrical chest movements with breath sounds throughout lung fields indicate proper tube placement.  Indicative of accumulation of secretions.  To open or maintain open airway in at rest or compromised individual.  To loosen up secretions.

2.Evaluate chest movement and auscultate for bilateral breath sounds

3. Monitor respiration and breathe sounds, noting rate and sounds. 4. Position patient to semifowler’s position. 5. Assist patient postural drainage percussion with and

Collaborative 1.Provide chest physiotherapy as indicated; postural drainage and percussion 2.Administer bronchodilators as ordered

 Promotes ventilation of lung segments and aid drainage of secretions  Promote ventilation and removal of secretions by relaxation of smooth muscle/ bronchospasm.

IDEAL NURSING CARE PLAN CUES Objectives:  Limited ROM  Slowed movement  Postural instability NURSING DIAGNOSIS Impaired physical mobility related to cerebral damage OBJECTIVES NURSING INTERVENTIONS Short Term Objectives Independent At the end of 8 hours 1. Assess functional nursing intervention the ability/extent of patient will be able to impairment initially on a  Be free from skin regular basis breakdown 2. Observe affected part for  Be free from factors color, edema or other signs that contribute of compromised pressure ulcers circulation. . 3. Inspect skin regularly Long Term Objectives especially over bony  At the end of 2 days prominence area nursing intervention, the patient will be 4. Maintain proper body able to: Maintain alignment with the support strength and of splints position function of affected or 5. Change positions at least compensatory body every 2 hours. parts. 6. Begin passive ROM to  Maintain skin all extremities. integrity.  SO will be able to 7. Provided for safety demonstrate measures like side rails interventions as needed Collaborative 1. Consult with occupational therapist as indicated. RATIONALE  Identifies strength and deficiencies and may provide information regarding recovery.  Edematous tissue is more easily traumatized and heals more slowly.  Pressure points over bony prominences are most at risk for decreased perfusion/ ischemia.  Promotes functional positioning of extremities and prevents and prevent contractures.  Reduce the risk of tissue ischemia or injury  Minimizes muscle atrophy, promotes circulation and helps prevent contractures.  Promote safety and prevent falls

 To develop individual exercise/mobility program.

IDEAL NURSING CARE PLAN CUES Objectives  Restlessness  Diaphoresis  Change in BP, RR, HR  Facial grimace NURSING DIAGNOSIS Altered Comfort: Acute pain related to increased intracranial pressure secondary to fluid accumulation in the intracranial space OBJECTIVES Short Term Objectives At the end of 1 hour nursing intervention, the patient will be able to:  Display relief of pain from 4/5 to 2/5.  Appear relaxed and able to sleep/rest appropriately. NURSING INTERVENTIONS RATIONALE Independent 1 Determine specifics of  Facilitate diagnosis of pain e.g. location, problem and initiation of characteristics, intensity (0appropriate therapy. 5 scale), onset/ duration, note nonverbal cues. 2. Encourage/maintain bed  Minimizes rest during acute phase. stimulation/promotes relaxation 3. Provide/recommend non  Measures that reduce Long Term Objectives pharmacologic measures for cerebral vascular  Learn the relief of headache. pressure and that slow/ different methods to block sympathetic provide relief. response are effective in  Follow prescribed relieving headache and pharmacologic associated complications. regimen. 4. Monitor vital signs  Change in vital signs regularly indicates acute pain and discomfort. 5. Provide comfort  To promote non measures such as touch, pharmacological pain positioning and back rub. management 6. Reposition patient every 2  To promote comfort, to 4 hours thus alleviating pain and promote circulation. Collaborative 1. Administer analgesic as ordered.  To provide Pharmacologic regimen for pain relief.

Ideal Nursing Care Plan Cues Objectives:  Increased body temperature above normal range  Flushed skin  Warm to touch  Unstable BP  Tachypnea  Tachycardia  Seizures Nursing Diagnosis Objectives Altered thermoregulation Short Term Objective: related to increase WBC At the end of 1 hour count in CBC secondary to nursing intervention the nasocomial infection as patient will be able to: evidence by presence of  Decrease body pseudomonas in the temperature from culture and sensitivity test. 38.4C to 37.0-37.5C.  Identify underlying cause of the increase in temperature Intervention Independent: 1. Monitor body temperature every 2 hours. 2. Provide tepid sponge bath to temperature >38. Rationale  Body temperature monitored every 2 hours.  Tepid sponge bath provided to temperature of >38.  Provided clean and a conducive environment to promote wellness and rest.  Ensured proper ventilation.


Long Term Objective: At the end of 8 hours the patient will be able to:  Maintain normothermia  Avoid complications such as brain damage or renal failure.  Be free of seizure activity

Provide clean and Conducive environment to promote wellness and rest. 4. Ensure proper ventilation.

5. Prepare at bedside necessary equipment for seizure episodes. 6. Monitor environmental temperature and limit clothing as indicated.

 Prepared at bedside necessary equipment for seizure episodes like tongue depressor.  Number of clothing should be altered to maintain near-normal body temperature

Collaborative: 1. Administer antipyretic medication (paracetamol) as ordered. 2. Administer antibiotic medications as ordered. 3. Administer IVF and regulate at desired rate as ordered.

 Administered antipyretic medication (paracetamol) as ordered.  Administered antibiotic medications as ordered.  Administered IVF and regulated at desired rate as ordered.

Ideal Nursing Care Plan Cues Objectives:  Skin lesion  Ulceration  Decubitus ulcer formation  Destruction of skin layers  Invasion of body structures  Display evidences of pain e.g: facial grimace, restlessness, diaphoresis. Nursing Diagnosis Objectives Impaired Skin Integrity Short Term Objective: related to decrease level At the end of 8 hours of activities as evidenced nursing intervention the by decubitus ulcer patient will be able to: formation on sacral  Participate in prevention area.. measures and treatment program  Be free from factors that can contribute further complications and infections Intervention Independent: 1.Assess/ document size, color, depth of wound, noting necrotic tissue and condition of surrounding skin 2.Repositoion frequently, Rationale  Provide baseline information and possible clues about circulation in area.  Improve skin circulation.  Clean, dry skin is less prone to infection and further breakdown  Reduces/ prevents skin irritation.  To protect the wound and surrounding tissues from contamination.  Moisture potentiates skin breakdown  Enhances commitment and cooperation to plan optimizing outcomes.

3.Wash and dry skin, especially in high moisture areas. 4.Keep bed clothes dry and free of crinkles, crumbs. 5. . Use appropriate Long Term Objective: dressings, wound At the end of 2 days the coverings. patient will be able to:  Display timely healing 6. Avoid use of plastic of pressure sores materials. without complication. 7. Assist the SO in  Maintain optimal understanding and nutrition following medical regimen  Demonstrate tissue and developing program regeneration. of preventive care and daily maintenance. Collaborative: 1.Administer topical wound ointment as ordered.

Collaborative:  To promote wound healing.  Improves systemic and

2.Provide kinetic therapy or alternating pressure mattress as indicated

3.Refer to dietician, as appropriate.

peripheral circulation and decreases pressure on skin, reducing breakdown.  For diet modification intended for the patient’s condition

IDEAL NURSING CARE PLAN CUES Objectives:  (+) seizures  Hypothermia  Immobile  Bedridden  Sedentary lifestyle NURSING DIAGNOSIS Risk for injury related to neuromuscular impairment OBJECTIVES Short Term Objectives At the end of 30 minutes nursing intervention the patient will be able to  Be free from injury  Achieve normal body temperature Long Term Objectives At the end of 8 hours nursing intervention, the patient will be able to:  Demonstrate characteristics presenting status that is free from injury  Maintain vital signs that are within normal range. NURSING INTERVENTIONS RATIONALE Independent  To monitor alteration in Independent: coordination, gait and 1.Assess muscle strength, balance gross, and fine motor coordination 2.Review history of prior  To predict current risk falls or injury associated for falls with immobility, weakness, prolonged bedrest, and unsafe environment 3. Monito patient’s cognitive  To recognize possible status. danger. 4. Assist SO in identifying  Visual- perceptual deficits any risk/ potential hazard increased the risk for falls and visual-perceptual deficits that may be present. 5. Provide quite room and  To minimize distraction less activity. and to provide therapeutic environment. 6.Raise side rails as  To provide patient’s indicated. safety, thus prevent fall. 7. Provide tepid sponge bath for fever.  To provide nonpharmacologic regiment for fever  Indicated for fever as  Indicated for fever.

Collaborative: 1. Administer anticonvulsants ordered. 2. Administer

antipyretic ordered.