The patient presented with pneumonia, septic shock, and stage IV oropharyngeal cancer. Nursing diagnoses included ineffective airway clearance related to increased secretions from the tracheostomy and impaired gas exchange related to mucus collection in the airways. Interventions included placing the patient in an upright position, instructing deep breathing and coughing, suctioning secretions as needed, providing humidified oxygen, and administering nebulized bronchodilators and mucolytics. Evaluation showed the goals were met with improved breathing and oxygen saturation after intervention.
The patient presented with pneumonia, septic shock, and stage IV oropharyngeal cancer. Nursing diagnoses included ineffective airway clearance related to increased secretions from the tracheostomy and impaired gas exchange related to mucus collection in the airways. Interventions included placing the patient in an upright position, instructing deep breathing and coughing, suctioning secretions as needed, providing humidified oxygen, and administering nebulized bronchodilators and mucolytics. Evaluation showed the goals were met with improved breathing and oxygen saturation after intervention.
The patient presented with pneumonia, septic shock, and stage IV oropharyngeal cancer. Nursing diagnoses included ineffective airway clearance related to increased secretions from the tracheostomy and impaired gas exchange related to mucus collection in the airways. Interventions included placing the patient in an upright position, instructing deep breathing and coughing, suctioning secretions as needed, providing humidified oxygen, and administering nebulized bronchodilators and mucolytics. Evaluation showed the goals were met with improved breathing and oxygen saturation after intervention.
Mr. Neil Ganchero, RN, MN Mr. Paul John Jalover, RN MN210 instructor Mrs. Michelle Lynn Lee, RN Nursing Rationale Nursing Rationale Evaluation Diagnosis Intervention Ineffective airway Normally the lungs are 1. Placed in upright 1. An upright position Goal met. clearance related to free from secretions. position ( if tolerated, provides for better increased secretions Pneumonia bacteria are the head of the bed at lung expansion and After immediate secondary to invading the lung 45 degree). Instruct improved air intervention, patient was tracheostomy as evidence parenchyma thus, the patient to assist in exchange. Position able to breath normally by excessive mucus producing inflammatory changing the position changes mobilize as manifested by production and difficulty process. And these every 2 hours. secretions. decreased respiratory of breathing. responses leading to rate from 30 breaths per filling of the alveolar sacs 2. Instill 0.5cc PNSS into minute to 22 breaths per 2. This will help with exudates leading to tracheostomy tube minute and patient O 2 stimulate coughing Subjective: consolidation. The airway sat remained > 95%. up of mucus and is narrowed thus wheezes add moisture to the “ na budlayan c misis mag is being heard. Difficulty mucucs ginhawa ky kadamo sang of breathing in some membranes. iya plemas,” as verbalized cases. by folk. 3. Suctioning is 3. Suctioned secretions indicated when as needed patients are unable Objective: to remove secretions from the -RR: 30bpm airway by coughing -CR: 110bpm because of -O2 sat: 91% weakness, thick -BP: 170/90 mmhg mucus plug, or -restlessness excessive or -diaphoresis tenacious mucus -hypoxemia production. It can -hypoxia also stimulate a -pallor cough. -dyspnea Nursing Rationale Nursing Rationale Evaluation Diagnosis Intervention The patient will maintain 4. Instruct the patient to 4. These measures clear, open airways, as deep breathe improve lung capacity evidenced by normal adequately, to cough andgas exchange. breath sounds, normal effectively. Coughing is the most rate and depth of effective way to remove respiration, and ability to most secretions. cough up secretions.
5. Maintain humidified 5. Increasing the
oxygen as prescibed. humidity of inspired air will reduce the viscosity of secretions and facilitate removal. Nursing Rationale Nursing Rationale Evaluation Diagnosis Intervention Impaired gas exchange Excess or deficit in 1. Placed in upright 1. An upright position Goal met. related to collection of oxygenation and carbon position ( if tolerated, provides for better mucus in airways as dioxide elimination at the the head of the bed at lung expansion and After immediate nursing evidenced by difficulty in alveolar-capillary 45 degree). Instruct improved air intervention, the goal breathing. membrane. the patient to assist in exchange. Position was met as evidenced by changing the position changes moilize O2 sat of 95%, cardiac every 2 hours. secretions. rate of 90bpm, BP of 130/ Objective: 80 mmhg, absence of -respiratory rate: 30bpm 2. Monitor vital signs 2. To obtain baseline dysnea. -cardiac rate: 120bpm including O2 -BP 170/90 mmhg saturation. 3. Bronchodilator + mucolytics increases -O2 sat of 90% 3. Nebulized as ordered patient’s secretion. -capillary refill of 2-3 (ipratropium salbutamol seconds + ambroxol 1cc) 4. Suctioning is indicated -paleness of the skin when patients are unable -irritability 4. Suctioned secretions as to remove secretions -dyspnea needed from the airway by coughing because of weakness, thick mucus plug, or excessive or Client will maintain tenacious mucus optimal gas exchange as production. It can also evidenced by stimulate a cough. arterial blood gasses (ABGs) within the client’s 5. Assess for changes in 5. Increased normal range, oxygen the level of restlessness, confusion saturation of 90% or consciousness. and/or irritability are greater, alert response early indicators of mentation or no further insufficient oxygenation reduction in the level of of the brain and require consciousness, and further interventions. relaxed breathing. Nursing Rationale Nursing Intervention Rationale Evaluation Diagnosis 6. Assess for changes in the 6. Tachycardia is associated client’s HR and temperature. with the increased work of breathing or hypoxia. Fever may develop in response to retained secretions or atelectasis.
7. Auscultate lung sounds, 7. Changes in lung sounds may
noting any areas of decreased reveal the cause of impaired ventilation or the presence of gas exchange. adventitious sounds.
8. Monitor arterial blood 8. Pulse oximetry is a useful
gasses and oxygen saturation. tool to detect early changes in oxygen saturation. Oxygen saturation should be kept at 90% or greater. Increasing PaCo2 and decreasing PaO2are signs of hypoxemia and respiratory acidosis. Nursing Rationale Nursing Rationale Evaluation Diagnosis Intervention Active infection related to Infection is the invasion 1. Institute airways 1. Accumulation of Goal met. surgical incision of of an organism’s body suctioning as needed. secretions provides a tracheostomy as tissues by disease-causing medium for bacterial After 8 hours of nursing evidenced by redness and agents, their growth. intervention, patient was presence of purulent multiplication, and the free from signs of discharges around the reaction of host tissues to 2. Provide tracheostomy 2. Good hygiene and infection as evidenced by stoma site. the infectious agents and care prevention of temperature of 37.1 from the toxins they produce. infection 38.1 and absence of redness around the 3. Assess skin integrity 3. This is a common site stoma site. Objective: under the tracheal for infection and skin -Temperature 38.1 ties. breakdown. -Swelling at stoma site -Redness at stoma site 4. Observe the stoma for 4. Observe the stoma for -Skin warm to touch erythema, color, erythema, color, exudates, and exudates, and crusting lesions. If crusting lesions. If present, culture the present, culture the stoma and notify the stoma and notify the physician. physician.
Patients remains free of 5. Observe the patient’s 5. Increased amounts of
infection, as evidenced by secretions for color, sputum and colored normal body consistency, quantity, or odorous secretions temperature, normal and odor. may indicate white blood cell count, infection. negative cultures, normal 6. Monitor sputum vital signs. cultures and 6. Identification of the sensitivities. infecting microorganism is important to determine antibiotic coverage.
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