Ncp For Aspiration Pnuemonia

ASSESSMENT

DIAGNOSIS

PLANNING

Subjective:

Activity Intolerance

“Nagapangluya siya kag indi siya mayad kahulag” as verbalize by the folks.

Related to: General weakness and imbalance between oxygen supply and demand.

After nursing intervention the patient will demonstrate a measurable increase in tolerance to activity with absence of lethargy and excessive fatigue, and vital signs within client’s acceptable range.

Objective: -

Lethargy Verbal reports of weakness Fatigue Exhaustion

INTERVENTION

RATIONALE

NURSING THEORY

Independent: a.) Evaluate client’s response to activity. Note reports of dyspnea, increased weakness / fatigue, an changes in vital signs during and after activities.

b.)Provide a quite environmental and limit visitors during acute phase as indicated. Encourage use of stress management and diversional activities as appropriate.

EVALUATION GOAL PARTIALLY MET

a.) Establishes patient’s capabilities / needs and facilitates choice of interventions.

Dorothy Johnson

b.) Reduces stress and excess stimulation, promoting rest.

Florence Nightingale

(Human Behavioral System) - This theory focuses on the balance to maintain stability in the system. It also focuses on the behavior of the patient threatened with illness. Also in the medicines that the patient is receiving.

(Environment theory) - Organizing and manipulating environment (physical, social, and psychosocial) in order to put the person in the best

After nursing intervention the patient were able to demonstrate measurable increase in tolerance to activity, but not totally. Vital signs within client’s acceptable range.

c.) Explain importance of rest in treatment plan and necessity for balancing activities with rest.

d.) Assist patient to assume comfortable position for rest / sleep.

g.) Assist with self – care activities as necessary. Provide for progressive

c.) Bed rest is maintained during acute phase to decrease metabolic demands, thus conserving energy for healing. Activity restrictions thereafter are determined by individual client response to activity and resolution of respiratory insufficiency. d.) Patient may be comfortable with the head of bed elevated, sleeping in a chair, or leaning forward on overboard table with pillow support.

g.) Minimizes exhaustion and helps balance

condition alleviate unnecessary pain and suffering. Dorothy Johnson (Human Behavioral System) - This theory focuses on the balance to maintain stability in the system. It also focuses on the behavior of the patient threatened with illness. Ida Jean Orlando (Nursing Process – ADPIE) - Nurses can help the patient what they cannot do to their self. Exploring the meaning of the need and validating the effectiveness of the action. Ida Jean Orlando

increase in activities during recovery phase.

oxygen supply and demand.

(Nursing Process – ADPIE) - Nurses can help the patient what they cannot do to their self. Exploring the meaning of the need and validating the effectiveness of the action.

ASSESSMENT Subjective:

DIAGNOSIS Ineffective Airway Clearance

“Gina ubo siya” As verbalized by the related to: folks. -Increased sputum Objective: production in response to - Inability to respiratory cough infection. effectively - Anxiety -Decreased - Dyspnea energy, fatigue - Dry cough

PLANNING -

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After 8 hours of nursing intervention the patient will be able to cough effectively and clear secretions. After 8 hours of duty the patient will display patent airway with breath sounds clearing, absence of dyspnea.

INTERVENTION

RATIONALE

NURSING THEORY

Independent:

a.) Monitor Vital signs every hours.

b.) Position patient in a moderated high position or semi fowler’s position. c.) Turn patient every two hours and PRN.

EVALUATION GOAL MET

a.) To asses baseline data of the patient.

b.) To promote maximal lung function.

c.) For repositioning , it promotes drainage of pulmonary secretions and it enhances ventilation to decrease

Dorothy Johnson (Human Behavioral System) - This theory focuses on the balance to maintain stability in the system. It also focuses on the behavior of the patient threatened with illness. Ida Jean Orlando (Nursing Process – ADPIE) - Nurses can help the patient what they cannot do to their self. - Exploring the meaning of the need and validating the effectiveness of the action.

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After the end of the shift, the patient is able to cough effectively and clear secretions. After the end of the shift, the patient display patent airway with breath sounds clearing, absence of dyspnea.

potential of atelectasis. d.) Provide oral care.

e.) Instruct patient or the folks regarding medications, side effects, and symptoms of adverse reaction to report to the nurse or physician. Dependent: a. Administer medication such as

Virginia Henderson d.) Secretions from CAP (14 components of are often foul Nursing Care) tasting and - Nurses will do smelling. what the things Providing that patients oral care cannot do. may - From decrease dependence to nausea and independence. vomiting associated with the taste of secretions. Hildegarde Peplau e.) Promotes prompt identification of potential adverse reaction to facilitate timely intervention.

(Basic care components - Orientation, Identification, Exploitation & Resolution.

Lydia Hall a.) A variety of

(Component of Nursing Care)

antibiotics and expectorants for productive cough. b. Instruct the patient or the folks to notify nurse if the patient is experiencing shortness of breath or air hunger.

medications are available to treat specific problems.

b.) It may indicate bronchial tubes are blocked with mucus, leading to hypoxia and hypoxemia.

- Care, Core and Cure. - Through medicines the patient can be cured and infection can be cured.

ASSESSMENT Subjective: “Wala siya mayad nagakaon, wala gana” as verbalize by the folks.

DIAGNOSIS

PLANNING

Risk for less than body requirements

After nursing intervention the patient will demonstrate a measurable increase in appetite and can tolerate her OTF of 1,500 kilocalories per day / 6 (250 cc of OTF per feeding)

Related to: - Increased metabolic needs

Objective: Sodium – 136.3 - Starvation - Diabetic acidosis - Dehydration

- Abdominal distension / gas associated with swallowing air during dyspneic episodes

INTERVENTION

BMI: 19.0

NURSING THEORY

Independent: a.) Provide covered container for sputum and remove at frequent intervals. Assist with / encourage oral hygiene after emesis, after aerosol and postural drainage treatments, and before meals.

Height: 152 cm Weight: 44 kg

RATIONALE

b.) Auscultate bowel sounds. Observe / palpate fro abdominal distention.

c.) Evaluate general nutritional state, obtain baseline

EVALUATION GOAL MET

a.) Eliminates noxious sights, tastes, smells from the patient environment and can reduce nausea.

Virginia Henderson

b.) Bowel sounds may be diminished / absent if the infectious process is sever / prolonged. Abdominal distention may occur as a result of air swallowing or reflect the influence of bacterial toxins on the gastrointestinal tract.

Ida Jean Orlando

c.) Presence of chronic conditions or financial

(14 components of Nursing Care) - Nurses will do what the things that patients cannot do.

(Nursing Process – ADPIE) - Nurses can help the patient what they cannot do to their self. Exploring the meaning of the need and validating the effectiveness of the action.

After nursing intervention the patient were able to demonstrate measurable increase in appetite and can tolerate her feeding.

weight.

limitations can contribute to malnutrition, lowered resistance to infection, and / or delayed response to therapy.

ASSESSMENT Subjective: “Nabudlayan siya mag ginhawa” As verbalized by the folks. Objective: -

Tachycardia Restlessness Dyspnea Hypoxia

DIAGNOSIS Impaired Gas Exchange related to: -Altered oxygencarrying capacity of blood / release at cellular level -Altered delivery of oxygen (hypoventilation)

PLANNING After 8 hours of duty, the patient will improved ventilation and oxygenation of tissues by ABGs within patient’s acceptable range and absence of symptoms of respiratory distress.

INTERVENTION

RATIONALE

NURSING THEORY

Independent: a.) Observe color of skin, mucous membranes, and nail beds, noting presence of peripheral cyanosis or central cyanosis.

b.) Assess mental status.

EVALUATION GOAL PARTIALLY MET

a.)

Cyan osis of nail beds may represent vasoconstriction or the body’s response to fever / chills; however, cyanosis of earlobes, mucous membranes, and skin around the mouth is indicative of systemic hypoxemia. b.) Restlessness, irritation, confusion, and somnolence may reflect hypoxemia / decreased cerebral oxygenation.

Hildegarde Peplau (Basic care components - Orientation, Identification, Exploitation & Resolution.

After 8 hours of duty, the patient was able to improved ventilation and oxygenation of tissues by ABGs within patient’s acceptable range and absence of symptoms of respiratory distress. pH - 7.45 (7.35 – 7.45) PCO2 - 41.3 (35 – 45 mmHg) PO2 - 46.0 (80 – 100 mmHg) HCO2 - 28.3 (22 – 26 mmol/L) TCO2 - 66.4

Dorothy Johnson c.) Monitor heart rate / rhythm

d.) Monitor body temperature. Assist with comfort measures to reduce fever and chills. e.) Maintain bedrest. Encouirage use of relaxation techniques and diversional activities. f.) Elevate head and encourage frequent position changes,

c.) Tachycardia is usually present as a result of fever / dehydration but may represent a response to hypoxemia. d.) High fever greatly increases metabolic demands and oxygen consumption and alters cellular oxygenation.

(Human Behavioral System) - This theory focuses on the balance to maintain stability in the system. It also focuses on the behavior of the patient threatened with illness.

e.) Prevents overexhaustion and reduces oxygen consumption / demands to facilitate resolution of infection.

f.) These measures promotes maximal inspiration, enhance expectorantion of secretions to improve ventilation.

Ida Jean Orlando (Nursing Process – ADPIE) - Nurses can help the patient what they cannot do to their self.

deep breathing, and ineffective coughing.

Exploring the meaning of the need and validating the effectiveness of the action. Dorothy Johnson

Dependent: a.) Monitor ABGs

a.) Follows progress of disease process and facilities alterations in pulmonary therapy

(Human Behavioral System) - This theory focuses on the balance to maintain stability in the system. It also focuses on the behavior of the patient threatened with illness.