NURSING CARE PLAN

ASSESSMENT

SUBJECTIVE:
OBJECTIVE:
(+) Wheezes at
both bases of
lungs
(+) weak and non
productive cough
Presence of
endotracheal (ET)
tube
Difficulty
vocalizing words
O2 sat: 92%
RR: 28 cpm

December 4, 2013

NURSING
DIAGNOSIS
Ineffective
airway
clearance
related to
impaired ability
to cough
secondary to
weakness of
muscles

SCIENTIFIC
EXPLANATION
Weakness of
respiratory
muscles

Decrease ability
to cough and
expectorate

Retained
secretions in the
airways

PLANNING
At the end of
the shift the
patient will
maintain a
patent airway at
all times AEB
the ff. Indicators
within normal
range:
RR (1220cpm)
O2 Sat
(95-99%)
Absence of
adventitiou
s breath
sounds
(-) use of
accessory
muscles

INTERVENTION

RATIONALE

Assess RR and breathing When secretion in the

pattern
airway the RR and depth
will be altered

EVALUATION

At the end of the shift the

patient have maintain a
patent airway at all times
AEB:
Auscultate breath sounds Breath sounds are normally RR= 21cpm
clear or a few scattered
O2 Sat (96%)
fine crackles at bases,
Absence of
which clear with deep
adventitious breath
breathing.
sounds
Minotor blood gas
(-) use of accessory
values and post oxygen
An O2 Sat of less than
muscles
saturation levels
90% and FIO2 of less than
21 signifies significant
oxygenation problems
Position the client to
semi fowlers
It allows for maximal lung
expansion
Suction the patient as
necessary
To remove excessive
secretions in the airways
Observe sputum noting
color and volume
To note any changes that
may aggravate condition
Administered O2 as
ordered
Oxygen administration
corrects hypoxemia

Administer medication
such as bronchodilators
or inhaled steroids.
ASSESSMENT
SUBJECTIVE:
OBJECTIVE:
FEEDING
Inability to:
Prepare her NGT
feeding
BATHING/
HYGIENE
Inability to:
Carry out hygienic
activities
Get bath supplies
and wash body
Obtain water
source
Dry body
DRESSING
Inability to:
Put clothing on
upper or lower

NURSING
DIAGNOSIS
Self-Care
Deficit in
bathing/
hygiene,
dressing/
grooming,
feeding and
toileting
related to
muscle
weakness and
general
fatigue

SCIENTIFIC
EXPLANATION
Communication
between muscle
and nerve is
interrupted

in
Acethylcholine
receptor sites at
the neuromuscular
junction

muscle
contraction

Muscle Weakness

Fatigability

Inability to
perform self care
like Feeding,
Dressing, Toileting
and Bathing

Bronchodilators decreases
airway resistance.

PLANNING

INTERVENTION

RATIONALE

At the end of
every shift the
patient will
perform selfcare activities
within level of
own ability
such as:
Combing hair
Oral and
Facial
Hygiene
Brushing teeth
Trimming nails
Dressing up
Use of bed pan
during
urination and
defecation

Avoid performing things for

patient that patient could
accomplish for self, but offer
help as appropriate. Permit as
much independence as
feasible.
Bathing or hygiene:
Foresee hygienic
requirements and calmly
support as necessary with care
of nails, skin, and hair, mouth
care, shaving.

It is imperative for patient to

do as much as possible for self
to sustain self-esteem and
uphold recuperation.

Make sure that necessary

things are within reach like
comb, nail cutter or mirror

This saves energy and ensures

safety.

Persuade patient to fix own

hair. Recommend hairstyles
that are not difficult to
maintain.

This allows the patient to

uphold independence for as
long as possible.

Provide privacy when

Necessitate for privacy is basic

Significant others illustration

can provide a matter-of-fact
tone for handling needs that
many be awkward to patient or
repulsive to significant other.

EVALUATION
At the end of
every shift the
patient have
performed selfcare activities
within level of
own ability such
as:
Combing hair
Oral and Facial
Hygiene
Brushing teeth
Trimming nails
Dressing up
Use of bed pan
during urination
and defecation

body
Put socks or shoes
Remove clothing
Maintain
appearance on
satisfactory level

TOILETING
Inability to:
Get to toilet or
commode
Manipulate
clothing for
toileting
To sit on or rise
from toilet or
commode
Flash toilet
Carry out proper
toilet hygiene

bathing/ assisting in bathing

as suitable

for most patients.

Support patient in performing

minimal oral-facial hygiene
after rising as feasible. Lend a
hand with brushing teeth and
shaving, as necessary. Help
out patient with care of
fingernails and toenails as
needed.

It is imperative for patient to

do as much as possible for self
to sustain self-esteem and
uphold recuperation

Ask patient to choose bath

time when energy is high.

The energy necessary for these

activities can be significant.
Rushing may lead to accidents.

Dressing or grooming:
Give privacy during dressing.

Patients possibly will take

longer time to dress and might
be fearful of violations in
privacy.

Give proper assistive devices

for dressing as evaluated
Offer makeup and mirror;
help out as necessary

The utilization of a button

hook or of loop and pile
closures on clothes could make
it feasible for a patient to
maintain autonomy in this self-

care activity.
Offer regular support and help Fine motor activities may take
as required with dressing.
additional coordinated actions
and may be further than the
capabilities of the patient.
Persuade utilization of
clothing one size bigger.

Toileting:
Assess or record prior and
present patterns for toileting;
introduce a toileting routine
that factors these habits into
the program
Evaluate patients capability
to communicate necessitate to
void and/or capacity to use
urinal, bedpan.
Give bedpan or put patient on
toilet every 1 to 1 hours
throughout day and three
times throughout night.

These decrease energy

spending and disappointment.

This facilitates simpler

dressing and comfort.

The efficacy of the bowel or

bladder program will be
improved if the natural and
personal patterns of the patient
are taken into consideration.
To determine when she will be
able to void or defecate

This saves energy, ensures

Give privacy while patient is

urinating/defecating

safety and promotes

dependency for toileting

Help patient in eliminating or

changing unnecessary
clothing.

Lack of privacy may reduce

the patients ability to empty
bowel and bladder.
Clothing that is not easy to get
in and out of may compromise
a patients capability to be
continent.

December 3, 2013

ASSESSMENT

SUBJECTIVE:
OBJECTIVE:

December 4, 2013

NURSING
DIAGNOSIS
Impaired
verbal
communicatio
n related to
presence of
endotracheal
tube

SCIENTIFIC
EXPLANATION

PLANNING

INTERVENTION

RATIONALE

EVALUATION

ASSESSMENT

SUBJECTIVE:
OBJECTIVE:
Impaired
swallowing
(+) ET tube
(+) tube
feedings
Depressed

NURSING
DIAGNOSIS
Risk for
aspiration r/t
impaired
swallowing
secondary to
presence of
endotracheal
tube

SCIENTIFIC
EXPLANATION
Weakness of
respiratory
muscles

Impaired ability
to swallow

Risk for
aspiration

PLANNING
The patient
will be free
from any
forms of
aspiration in
the entire 8
hours shift
AEB:
(-) s/sx of
aspiration

INTERVENTION

RATIONALE

Monitor V/S esp. RR,

depth and effort, noting
the s/s of aspiration
(dyspnea,cough,cyanosis
,wheezing)

Signs of aspiration should be

detected to prevent aspiration

Auscultate lung sounds

before and after
feedings; note any new
onset of crackles or

To monitor for signs of

aspiration and infection

EVALUATION
The patient was free
from any forms of
aspiration in the entire
8 hours shift AEB:
(-) s/sx of aspiration
such as dyspnea,
cough,, cyanosis,
wheezing, hoarseness,
foul smelling sputum
or fever

gag reflex
(+) hyper
secretion

December 4, 2013

ASSESSMENT

Risk factors includes

the ff:
Corticosteroi
d therapy
(Cellcept)

such as
dyspnea,
cough,,
cyanosis,
wheezing,
hoarseness,
foul smelling
sputum or
fever

wheezing

Decrease
secretion in
the mouth

NURSING
SCIENTIFIC
PLANNING
DIAGNOSIS EXPLANATION
Risk for
Use of Cellcept The patient
infection r/t

will be free
corticosteroids Immunossuppres from any
secondary to
sion
forms of
immunosuppre

infection in
ssion
Decreased
the entire 8

Keep HOB elevated at

semi fowlers position.

It helps decrease aspiration

pneumonia

Provide meticulous oral

care including brushing
of teeth at least 2 times
per day

Good oral care can prevent

bacterial on fungal
contamination of mouth which
can be aspirated

Suction as needed.

To clear airway from the

secretion

Administer
anticholinergic drugs as
ordered

Anticholinergic agent that

specifically antagonizes the
muscarine like activity to
acetylcholine and other
cholinesters

INTERVENTION

RATIONALE

Monitor V/S esp. RR

and temperature

To note any changes in status

Observe sputum color

and characteristic

To monitor signs of infection.

Decrease
secretion in the
mouth

EVALUATION
The patient will be free
from any forms of
infection in the entire 8
hours shift AEB:
(-) s/sx of infection

Presence of
ET tube
36.8C
(-) Dyspnea
Lymphocyte
s 0.05
(-)
Adventitiou
s Breath
sounds

December 4, 2013

circulating white
blood cell

Decreased ability
to fight infection

Increased
susceptibility of
infection

hours shift
AEB:
(-) s/sx of
infection such
as dyspnea,
cough,
wheezing, foul
smelling
sputum or
fever

Auscultate lung sounds

for every 4 hours note
any new onset of
crackles or wheezing

To monitor for signs of

infection.

Monitor CBC

To detect any early signs of

infection.

Assess patency and

placement of nasogastric
tube

A displace tube mat cause

infection.

Observe and report

signs of infection such as
Warmth, discharge,
They are possible signs of
chills and mental status. infection.
Elevate head of bed 30
or higher

It prevents gastric reflux of

organisms in the lungs.

Use of appropriate Hand

hygiene techniques

Handwashing is the best strategy

for redusing transmission of
organisms

Ensure the clients

appropriate hygienic care
with handwashing and
oral care.

Daily showers or baths can help

to reduce the number of bacteria
on the clients skin. The oral
cavity is a common site for
infection

such as dyspnea,
cough, wheezing, foul
smelling sputum or
fever

Administer antibiotics as
ordered

For pharmacological
management