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NURSING CARE PLAN CUES Subjective: The patient verbalizes “Nabudlayan ako mag ginhawa.”
NURSING DIAGNOSIS
RATIONALE
GOAL
Ineffective airway clearance r/t increased production of thick and viscous secretions
Chronic cough and sputum production often precede the development of airflow limitation. The mucusproducing bronchial wall hypertrophy and increased in number consequently the increase mucus secretions affect the flow of air and exchange of gas and may predispose the client to plugging and infection. Long standing infection results in destruction of lung tissue. With infection, the amount of sputum becomes more copious and purulent. Breathlessness on exertion occurs with increasing severity.
After 8 hours of nursing interventions the client will be able to: 1. Demonstrate effective coughing and clear breath sounds. 2. Maintain patent airway at all times. 3. Relate methods to enhance secretion removal. 4. Identify and avoid specific factors that inhibit effective airway clearance.
Objective: > >
> >
RR23bpm(slightly tachypneic) Abnormal breathe sounds (wheeze, crackles) Cough with sputum Decrease respiratory excursion.
Definition: A state in which an individual is unable to clear secretions from respiratory tract to maintain airway patency. Reference: Nurses’ Pocket Guide By: Doenges,Marilyn 4th edition page 67
NURSING INTERVENTIONS
RATIONALE
Independent: 1. Position the client in an upright 1. An upright or semi-Fowler’s position facilitates in lung or semi-Fowler’s position. expansion. 2. Encourage to take in fluids and 2. This liquefies secretions for easy expectoration. promote hydration. 3. Using touch on the shoulder, 3. The nurses’ presence, reassurance, and help in coach the client to slow controlling the client’s respiratory rate demonstrating breathing can be very slow respirations; making eye beneficial in decreasing contact with the client; and anxiety. communicating in a calm, supportive fashion. 4. Note pattern of respiration.
4. Symptoms may be masked by chronic respiratory conditions common among older adults.
the 5. Monitor respiratory rate, depth, 5. Understanding underlying cause of and ease of respiration. patient’s particular ventilatory problem is essential to the care of patient 6. Note abdominal breathing, use 6. These symptoms signal increasing respiratory of accessory muscles, nasal difficulty and increasing flaring, retractions, irritability, hypoxia. confusion, or lethargy.
EVALUATION After 8hrs of nursing intervention, Goal partially met: Client demonstrates effective coughing as evidenced by expectoration of secretions. Crackles and wheezing were decreased in all lung fields. The client was able to breathe with ease as evidenced by a decreased in respiratory rate from 23 to 20 breath per minute.
• Collaborative: 1. Administer medications as 1. indicated: > This drug relaxes bronchial > Salbutamol(Ventolin) and through nebulization > This relaxes smooth muscles > Theophylline(Asmasolo of the bronchial tree and n) pulmonary blood vessels. CNS stimulation(including the respiratory center)
>
Bambuterol(Bambec)
2. Administer O2 inhalation 2lpm via nasal cannula.
> This drug stimulates betareceptors thus producing relaxation of bronchial smooth muscles. 2. To facilitate the demand of oxygen in the body. And help in dyspnea.
NURSING CARE PLAN
CUES
NURSING DIAGNOSIS
RATIONALE
GOAL
NURSING INTERVENTIONS • Independent 1. Ascertain patient’s beverage preferences, and set up a 24hr schedule for fluid intake. Encourage foods with high fluid content. 2. Monitor urinary output. Measure/estimate fluid losses from all sources.
Fluid volume deficit r/t Diarrhea Subjective: The patient verbalizes “gatubig akon pamus-on.” Objective: Hyperactive bowel sounds Poor skin turgor Dry skin Edema at the left leg and left forearm. Sodium(129 mmol/L) Creatine(137.02 mmol/L)
Definition: The state in which an individual experiences vascular, cellular or intracellular deutoration (in excess of needs or replacement capabilities due to failure of regulatory mechanisms.
FVD results from loss of body fluid intake. FVD can develop from inadequate intake alone if the decreased intake is prolonged. Cause of FVD includes abmormal fluid losses. Such as, vomiting, nausea, diarrhea, sweating or inability to gain access to fluid.
After 8 hours of nursing interventions the client will be able to: 1. Maintain fluid volume at a functional level. 2. Verbalize understanding of causative factors and purpose of therapeutic intervention. 3. Demonstrate behaviors participate and correct fluid loss as indicated.
3. Monitor for sudden/marked elevation of BP, restlessness, moist cough, dyspnea, basalar crackles, frothy sputum. 4. Weigh daily and compare with 24-hr fluid balance. Mark/measure edematous areas, e.g., abdomen, limbs.
5. Evaluate patient’s ability to swallow.
Reference:
6. Provide skin and mouth care. Bathe every other day using mild soap. Apply lotion as indicated.
Nurses’ Pocket Guide By: Doenges,Marilyn
7. Turn frequently, massage skin, and protect bony prominences.
th
RATIONALE
EVALUATION
1. Relieves thirst and discomfort of dry mucous membranes and augments parenteral replacement. 2. Fluid replacement needs are based on correction of current deficits and ongoing losses. A decreased urinary output may indicate insufficient renal perfusion/hypovolemia, or polyuria can be present, requiring more aggressive fluid replacement. 3. Too rapid a correction of fluid deficit may compromise the cardiopulmonary system, especially if colloids are used in general fluid replacement. 4. Although weight gain and fluid intake greater than output may not accurately reflect intravascular volume, e.g., thirdspace fluid accumulation cannot be used by the body for tissue perfusion, these measurements provide useful data for comparison. 5. Impaired gag/swallow reflexes, anorexia/nausea, oral discomfort, and changes in level of consciousness/ cognition are among the factors that affect patient’s ability to replace fluids orally. 6. Skin and mucous membranes are dry, with decreased elasticity, because of vasoconstriction and reduced intracellular water. Daily bathing may increase dryness.
After 8 hours of nursing interventions Goal partially met: • Maintain fluid volume at a functional level as evidenced by stable vital signs, moist mucous membranes, good skin turgor, and prompt capillary refill. Demonstrat e behaviors to monitor and correct deficit as appropriate.
Filamer Christian College College of Nursing Roxas City
DRUG STUDY Name of Patient: L. M. Area/Bed No.: _____________________________ Name of Drug Generic Name:
Method of Administration Route:
Salbutamol
Neb
Brand Name:
Timing:
Ventolin
Stat
Classification:
Dosage:
Anti-asthma/ Bronchodilator
1 neb
Available forms:
Frequency:
Nebule
Age/Sex: 78 years old , male Impression: _______________ Mechanism of Action
Adverse Reaction
Attending Physician: Dr. B______________ Date: April 22, 2008_______________ Special Consideration
Nursing Responsibilities
Rationale
Relaxes bronchial and Bronchospasm, enterine smooth muscle Hypersensitivity by acting on beta- reactions adrenergic receptors
OccuNeb has not been 1. Monitor VS, measure 1. Expected clinical studied for treating acute and record effects include bronchospasms. intake/output. improvement in quality of pulse and respiration. 2. Warn patient of side 2. Dizziness is a effects.(dizziness) common adverse reaction at start of therapy.
Indications: Relief of bronchospasm in bronchial asthma, chronic bronchitis, emphysema, obstructive pulmonary disease.
Contraindications: Patient with hypersensitivity to drug or its ingredients.
Side Effects: Tremor, nervousness, dizziness, insomnia, headache, weakness, tachycardia and irritated nose and throat, nasal congestion, nausea, increased sputum, cough muscle cramps.
NURSING DIAGNOSIS
RATIONALE
GOAL
Ineffective airway clearance r/t increased production of thick and viscous secretions
Chronic cough and sputum production often precede the development of airflow limitation. The mucusproducing bronchial wall hypertrophy and increased in number consequently the increase mucus secretions affect the flow of air and exchange of gas and may predispose the client to plugging and infection. Long standing infection results in destruction of lung tissue. With infection, the amount of sputum becomes more copious and purulent. Breathlessness on exertion occurs with increasing severity.
After 8 hours of nursing interventions the client will be able to: 1. Demonstrate effective coughing and clear breath sounds. 2. Maintain patent airway at all times. 3. Relate methods to enhance secretion removal. 4. Identify and avoid specific factors that inhibit effective airway clearance.
Objective: > >
> >
RR23bpm(slightly tachypneic) Abnormal breathe sounds (wheeze, crackles) Cough with sputum Decrease respiratory excursion.
Definition: A state in which an individual is unable to clear secretions from respiratory tract to maintain airway patency. Reference: Nurses’ Pocket Guide By: Doenges,Marilyn 4th edition page 67
NURSING INTERVENTIONS
RATIONALE
Independent: 1. Position the client in an upright 1. An upright or semi-Fowler’s position facilitates in lung or semi-Fowler’s position. expansion. 2. Encourage to take in fluids and 2. This liquefies secretions for easy expectoration. promote hydration. 3. Using touch on the shoulder, 3. The nurses’ presence, reassurance, and help in coach the client to slow controlling the client’s respiratory rate demonstrating breathing can be very slow respirations; making eye beneficial in decreasing contact with the client; and anxiety. communicating in a calm, supportive fashion. 4. Note pattern of respiration.
4. Symptoms may be masked by chronic respiratory conditions common among older adults.
the 5. Monitor respiratory rate, depth, 5. Understanding underlying cause of and ease of respiration. patient’s particular ventilatory problem is essential to the care of patient 6. Note abdominal breathing, use 6. These symptoms signal increasing respiratory of accessory muscles, nasal difficulty and increasing flaring, retractions, irritability, hypoxia. confusion, or lethargy.
EVALUATION After 8hrs of nursing intervention, Goal partially met: Client demonstrates effective coughing as evidenced by expectoration of secretions. Crackles and wheezing were decreased in all lung fields. The client was able to breathe with ease as evidenced by a decreased in respiratory rate from 23 to 20 breath per minute.
• Collaborative: 1. Administer medications as 1. indicated: > This drug relaxes bronchial > Salbutamol(Ventolin) and through nebulization > This relaxes smooth muscles > Theophylline(Asmasolo of the bronchial tree and n) pulmonary blood vessels. CNS stimulation(including the respiratory center)
>
Bambuterol(Bambec)
2. Administer O2 inhalation 2lpm via nasal cannula.
> This drug stimulates betareceptors thus producing relaxation of bronchial smooth muscles. 2. To facilitate the demand of oxygen in the body. And help in dyspnea.
NURSING CARE PLAN
CUES
NURSING DIAGNOSIS
RATIONALE
GOAL
NURSING INTERVENTIONS • Independent 1. Ascertain patient’s beverage preferences, and set up a 24hr schedule for fluid intake. Encourage foods with high fluid content. 2. Monitor urinary output. Measure/estimate fluid losses from all sources.
Fluid volume deficit r/t Diarrhea Subjective: The patient verbalizes “gatubig akon pamus-on.” Objective: Hyperactive bowel sounds Poor skin turgor Dry skin Edema at the left leg and left forearm. Sodium(129 mmol/L) Creatine(137.02 mmol/L)
Definition: The state in which an individual experiences vascular, cellular or intracellular deutoration (in excess of needs or replacement capabilities due to failure of regulatory mechanisms.
FVD results from loss of body fluid intake. FVD can develop from inadequate intake alone if the decreased intake is prolonged. Cause of FVD includes abmormal fluid losses. Such as, vomiting, nausea, diarrhea, sweating or inability to gain access to fluid.
After 8 hours of nursing interventions the client will be able to: 1. Maintain fluid volume at a functional level. 2. Verbalize understanding of causative factors and purpose of therapeutic intervention. 3. Demonstrate behaviors participate and correct fluid loss as indicated.
3. Monitor for sudden/marked elevation of BP, restlessness, moist cough, dyspnea, basalar crackles, frothy sputum. 4. Weigh daily and compare with 24-hr fluid balance. Mark/measure edematous areas, e.g., abdomen, limbs.
5. Evaluate patient’s ability to swallow.
Reference:
6. Provide skin and mouth care. Bathe every other day using mild soap. Apply lotion as indicated.
Nurses’ Pocket Guide By: Doenges,Marilyn
7. Turn frequently, massage skin, and protect bony prominences.
th
RATIONALE
EVALUATION
1. Relieves thirst and discomfort of dry mucous membranes and augments parenteral replacement. 2. Fluid replacement needs are based on correction of current deficits and ongoing losses. A decreased urinary output may indicate insufficient renal perfusion/hypovolemia, or polyuria can be present, requiring more aggressive fluid replacement. 3. Too rapid a correction of fluid deficit may compromise the cardiopulmonary system, especially if colloids are used in general fluid replacement. 4. Although weight gain and fluid intake greater than output may not accurately reflect intravascular volume, e.g., thirdspace fluid accumulation cannot be used by the body for tissue perfusion, these measurements provide useful data for comparison. 5. Impaired gag/swallow reflexes, anorexia/nausea, oral discomfort, and changes in level of consciousness/ cognition are among the factors that affect patient’s ability to replace fluids orally. 6. Skin and mucous membranes are dry, with decreased elasticity, because of vasoconstriction and reduced intracellular water. Daily bathing may increase dryness.
After 8 hours of nursing interventions Goal partially met: • Maintain fluid volume at a functional level as evidenced by stable vital signs, moist mucous membranes, good skin turgor, and prompt capillary refill. Demonstrat e behaviors to monitor and correct deficit as appropriate.
Filamer Christian College College of Nursing Roxas City
DRUG STUDY Name of Patient: L. M. Area/Bed No.: _____________________________ Name of Drug Generic Name:
Method of Administration Route:
Salbutamol
Neb
Brand Name:
Timing:
Ventolin
Stat
Classification:
Dosage:
Anti-asthma/ Bronchodilator
1 neb
Available forms:
Frequency:
Nebule
Age/Sex: 78 years old , male Impression: _______________ Mechanism of Action
Adverse Reaction
Attending Physician: Dr. B______________ Date: April 22, 2008_______________ Special Consideration
Nursing Responsibilities
Rationale
Relaxes bronchial and Bronchospasm, enterine smooth muscle Hypersensitivity by acting on beta- reactions adrenergic receptors
OccuNeb has not been 1. Monitor VS, measure 1. Expected clinical studied for treating acute and record effects include bronchospasms. intake/output. improvement in quality of pulse and respiration. 2. Warn patient of side 2. Dizziness is a effects.(dizziness) common adverse reaction at start of therapy.
Indications: Relief of bronchospasm in bronchial asthma, chronic bronchitis, emphysema, obstructive pulmonary disease.
Contraindications: Patient with hypersensitivity to drug or its ingredients.
Side Effects: Tremor, nervousness, dizziness, insomnia, headache, weakness, tachycardia and irritated nose and throat, nasal congestion, nausea, increased sputum, cough muscle cramps.
