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Far Eastern University Institute of Nursing Second Semester, SY 2011-2012 NURSING CARE PLAN Date: February 14, 2012

Patient: J.P.P. Age: 24 years old Cues Nursing Diagnosis Analysis Sex: male Case: CAP- MR PTB 5

Goal and Objectives Goal: After 8 hours of nursing interventions , the client will have improved airway clearance as evidenced by effective coughing techniques and a patent airway.

Nursing interventions

Rationale

Evaluation

Subjective:

Ineffective airway Client clearance verbalized, related to Hindi ako retained maka-ubo secretions ng maayos. as Parang manifested andami by kong plema ineffective pero hindi cough ko mailabas.

Objective: - (+) crackles upon auscultation -dyspnea Vital Signs as of February 14, 2012, 8:00 pm RR: 29 cpm BP: 90\60

Airway obstructio n involves partial or complete occlusion of the passage ways in the bronchi and lungs most often due to increased accumula tion of mucus or inflammat ory exudate. Thus, the client may have altered arterial blood gas levels, restless, dyspnea

Was the client able to have an effective airway clearance as evidenced by effective coughing techniques and a patent airway? Yes ___

Objectives: After 2 hours of nursing interventions , the client will be able to expectorate secretions. 1.Monitor lung sounds every 4 to 8 hours and before and after coughing episodes. 1.Adventiti ous breath sounds present in the large airways may impair airway patency. (MedicalNo ___

Was the client able to expectorat e secretions

Temp: 38.3C PR: 76 bpm

and adventitio us breath sounds. (Fundam entals of Nursing by Kozier and Erbs 8th edition, vol.2 p.1364.)

Surgical Nursing, 8th edition, Black and Hawks, page 1582)

? Yes ___ No ___

2.Teach the client to maintain adequate hydration by drinking atleast 8 to 10 glasses of fluid per day (if not contraindicate d).

2.Hydratio n helps to thin secretions . (MedicalSurgical Nursing, 8th edition, Black and Hawks, page 1582)

3.Teach and supervise effective coughing exercises.

3.Proper coughing technique s conserve energy, reduce airway collapse and lessen client frustration. (MedicalSurgical Nursing, 8th edition, Black and Hawks, page 1582)

After 2 hours of nursing interventions , the client will be able to maintain airway patency.

1.Position head appropriate for condition.

1.To open or maintain open airway in at-rest or compromi sed individual (NANDA 11th edition, page 79, Doenges, Marilyn E.) 2.To maximize effort (NANDA 11th edition, page 79, Doenges, Marilyn E.)

Was the client able to maintain airway patency? Yes ___ No ___

2.Encourage or assist with abdominal or pursed lip breathing exercise.

After 2 hours of nursing interventions , the client will be able to demonstrate an absence or reduction of congestion with clear breath sounds.

1.Perform chest physiotherapy, if needed, and instruct the client and significant others in these techniques.

1.Chest physiother apy technique s use forces of gravity and motion to facilitate secretion removal. (MedicalSurgical Nursing, 8th edition, Black and

Was the client able to demonstrat e an absence or reduction of congestion with clear breath sounds? Yes ___ No ___

Hawks, page 1582) 2.Elevate head of the bed/change position every 2 hrs and PRN. 2.To take advantage of gravity decreasin g pressure on diaphrag m and enhancing drainage of/ventilati on to different lung segments (NANDA 11th edition, page 7879, Doenges, Marilyn E.) 3.To ascertain status and note progress (NANDA 11th edition, page 80, Doenges, Marilyn E.) 4.Thick secretions line the mouth when the

3.Observe for signs of respiratory distress(increa sed rate, restlessness/ anxiety, use of accessory muscles for breathing)

4. Assess the condition of the oral mucous membranes

and perform or client offer oral care coughs; every 2 hours. oral care removes them. (MedicalSurgical Nursing, 8th edition, Black and Hawks, page 1582)

After 2 hours of nursing interventions , the client will be able to demonstrate behaviors to improve or maintain clear airway.

1.Provide information about the necessity of raising and expectorating secretions versus swallowing them.

1.To report changes in color and amount in the event that medical interventio n may be needed to prevent/tr eat infection (NANDA 11th edition, page 80, Doenges, Marilyn E.) 2.Prevent s/reduces fatigue (NANDA 11th edition, page 80, Doenges,

Was the client able to demonstrat e behaviors to improve or maintain clear airway? Yes ___ No ___

Effectivity: Was the expected outcome met? Yes ___ No ___

2.Encourage / provide opportunities for rest; limit activities to level of respiratory tolerance.

Marilyn E.)

Efficiency: Were the available resources of the patient used accordingly ? Yes ___ No __

Adequacy: Did the plan of care meet the expectatio ns of the patient? Yes ___ No ___

Appropriat eness: Did the interventio ns meet the patients health needs? Yes ___

No ___

Acceptabili ty: Was the plan of care acceptable to the patient? Yes ___ No ___