3817231 Nursing Care Plan Sample

NURSING CARE PLAN DATE/ SHIFT ASSESSMENT S/O with O2 inhalatio n via nasal cannula crackling sound heard upon lung auscultation intermitte nt cough noted unproductive cough weak RR24bpm NEED P H Y S I O L O G Y / O X Y G E N A T I O N NURSING DIAGNOSIS Ineffective airway clearance related to retained secretions secondary to PTB. ®PTB is a chronic, recurrent, infection caused by some bacteria. The common TB popular in the Philippines & other Asian countries is Pulmonary (lung), due to M. Tuberculosis. A person who acquired this kind of bacteria from a person by sneezing, coughing, talking, will enter to the lungs and may grow to produce secretions. These secretions may lodge to airways if not coughed up. There will be an ineffective airway clearance. Source: http://www.sebudoctorsun iversity.edu/hospital/cardi o/chua183.html J A N U A R Y 24-26, 2 0 0 8 PLAN OF CARE Within 8 hours span of nursing care will be able to: a.) expectorate secretions b.) demonstrate intervention such as deep breathing NURSING INTERVENTION 1. Auscultated breath sounds & assessed air movement to ascertain status & note progress. 2. Elevated head of the bed/change position every 2 hours & prn to take advantage of gravity decreasing pressure on the diaphragm & enhancing drainage of ventilation to diff. lung segments. 3. Encouraged deep breathing & coughing exercise ®promotes optimal chest expansion & drainage of secretions. 4. Encouraged increase fluid intake ®to help liquefy secretions 5. Encouraged/provided warm versus cold liquids as appropriate. 6. Provided supplemental humidification, if needed (nebulizer, O2 inhalation) 7. Provided back tapping after nebulization to move the secretions in the lungs. EVALUATION -