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Nursing Care Plans

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION


Subjective:
-

Objective:
Dyspnea
Dysphagia
Dysarthria
Irritable and
restless
Coughing reflex
very minimal
Whitish to yellowish
and very thick
phlegm
Crackles
Weak breath
sounds
Effortful breathing
With 0
2
tank
dependence :
regulated 8-10lpm
Skin is pale and cold
Capillary refill of
4secs.
Left and right ear
are not responsive
to verbal approach/
sound stimulation

BP: 110/60
P: 120
RR: 30
T: 36.7


Ineffective
Airway
Clearance r/t
retained lung
secretions as
manifested by
difficulty of
breathing
Short term:
After 8 hours of nursing
interventions the client
will be able to:
Maintain patent
airway and use of
oxygen mask.
Expectorate secretions
readily
Demonstrate deep
breathing exercise




Long Term:
After 3 days of nursing
interventions client will
be able to:
Reports absence of
congestion with
breath sounds clear,
respiration
noiseless, improved
oxygen exchange


INDEPENDENT :
1. Monitor rate, rhythm, depth,
and effort of respirations.

2. Note chest movement,
watching for symmetry, use of
accessory muscles, and
supraclavicular and intercostal
muscle retractions.

3. Monitor for increased
restlessness, anxiety, and air
hunger.

4. Assisted client to maintain a
comfortable position to
facilitate breathing by elevating
the head of bed, leaning on or
over bed table, or sitting on
edge of bed.

5. Auscultate breath sounds,
noting areas of decreased or
absent ventilation and presence
of adventitious sounds.

6. Encourage her to take several
deep breaths.

7. Promote systemic fluid
hydration, as appropriate.

DEPENDENT :
1. Institute respiratory therapy
treatments (e.g., nebulizer) as
needed.

2. Regulate O
2
tank as ordereded
by the doctor

INDEPENDENT :
1. Provides a basis for evaluating adequacy of
ventilation.

2. Presence of nasal flaring and use of accessory
muscles of respirations may occur in response
to ineffective ventilation.

3. These clinical manifestations would be early
indicators of hypoxia.

4. Elevation of the head of the bed facilitates
respiratory function using gravity; however,
client in severe distress will seek the position
that most eases breathing. Supporting arms
and legs with table, pillows, and so on helps
reduce muscle fatigue and can aid chest
expansion.

5. As fluid and mucus accumulate, abnormal
breath sounds can be heard including crackles
and diminished breath sounds owing to fluid-
filled air spaces and diminished lung volume.

6. Deep breathing promotes oxygenation before
controlled coughing.

7. Adequate fluid intake enhances liquefaction
of pulmonary secretions and facilitates
expectoration of mucus.


DEPENDENT
1. A variety of respiratory therapy treatments
may be used to open constricted airways and
liquefy secretions.

2. Used to correct and prevent worsening of
hypoxemia, improve survival, and quality of
life. Supplemental oxygen can be provided
during exacerbations only, or as a long-term
therapy.
Short term:
After 8 hours of
nursing interventions
the client was be able
to:
Maintain patent
airway and use of
oxygen mask.
Expectorate
secretions readily
Demonstrate deep
breathing exercise





Long Term:
After 3 days of
nursing interventions
client was be able to:
Reports absence of
congestion with
breath sounds
clear, respiration
noiseless, improved
oxygen exchange

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