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West Visayas State University

College of Nursing
La Paz, Iloilo City

NURSING CARE PLAN

Clustered Cues Nursing Diagnosis Rationale Outcome Criteria Nursing Rationale Evaluation
Interventions
Ineffective airway Ineffective airway The client will be Auscultate breath Decreased airflow
clearance related to clearance is the able to maintain a sounds, noting areas occurs in areas
lung impairment and inability to clear patent airway by if decreased or consolidated with
retained secretions in secretions or absent airflow and fluid. Bronchial
managing secretions
surgery. obstructions from the adventitious breath breath sounds can
respiratory tract to with hydration, sounds. also occur in
maintain a clear effective coughing consolidated areas.
airway. and suctioning as Crackles can be
necessary evidenced heard in inspiration
Gunshot wounds are by clear breath in response to fluid
the most common sounds upon accumulations and
types of penetrating thick secretions.
auscultation, eupnea,
chest trauma. They
are classified and ability to cough Assess rate and Tachypnea and
according to the out secretions by depth of respiration shallow respirations
velocity. Gunshot and chest are frequently
wounds to the chest movement. present because of
maybe classified as discomfort of moving
of low, medium, or chest wall or fluid in
high velocity. The lung.
factors that
determine the Assess changes in Tachycardia and
velocity and resulting vital signs. hypertension may be
extent of damage related to increased
include the distance work of breathing
from which the gun and hypoxia. Fever
was fired, the caliber may develop in
of the gun, and response to retained
construction and the secretions.
size of the bullet. A Elevate head of bed. Lowers diaphragm
gunshot wound can promoting chest
produce a variety of expansion, aeration
pathophysiologic of lung segments
changes. A bullet can and expectoration of
cause damage at the lung secretions.
site of penetration
and along its Assist patient with Deep breathing
pathway. It also may frequent deep facilitates maximum
ricochet of bony breathing exercises. expansion of the
structures and lungs or smaller
damage the chest airways.
organs.
Demonstrate patient Coughing is a natural
Blunt chest trauma learn to perform self-cleaning
results from sudden activity and effective mechanism assisting
compression coughing while in the cilia to maintain
or positive pressure semi-Fowler’s or patent airways. An
inflicted to the chest upright position. upright position
wall. Motor vehicle favors deeper more
crashes (trauma due forceful cough effort.
to steering wheel,
seat belt), falls, and Assess for abdominal Pain can result in
bicycle or thoracic pain; shallow breathing
crashes (trauma due allow client to and an ineffective
to handlebars) are
identify factors cough.
the most common
causes causing pain.
of blunt chest Airway clearance is
Assess hydration
trauma.
status; skin turgor, impaired with
Pneumothorax mucus membranes, inadequate hydration
occurs when the tongue. and subsequent
parietal and visceral secretion thickening.
pleura is breached
and the pleural space Advise the client to Fluids especially
is exposed to positive increase fluid intake. warm liquids aid in
atmospheric Offer warm rather mobilization and
pressure. Normally, cold fluids. expectoration of
the pressure in the secretions.
pleural space is
negative; this Administer Aids in the
negative pressure is medications as mobilization of
required to maintain ordered. secretions.
lung inflation. When
either pleura is Perform chest Chest physiotherapy
breached, air enters physiotherapy and is the final technique
the pleural space and suction as indicated. for maintaining a
the lung or a portion patent airway. If a
of it collapses. patient is identified
as being at high risk
Traumatic for developing
pneumothorax postoperative
occurs when air pulmonary
escapes from a complications, then
laceration from the chest physiotherapy
lung itself and enters is started
the pleural space. In immediately
the chest wall. It can (perhaps even before
occur with blunt surgery). The
trauma or techniques of
penetrating chest postural drainage,
trauma vibration, and
percussion help to
Traumatic loosen and mobilize
pneumothorax may the secretions so
occur with invasive that they can be
thoracic procedures coughed up or
in which the pleura is suctioned.
inadvertently
punctured. Traumatic
pneumothorax
resulting from major
injury to the chest is
often accompanied Sources:
by hemothorax. Doenges M. et. Al.
11th ed. Nurses
Chest surgery can pocket guide.
cause what is Medical-Surgical
classified as a Nursing 2004 7th
traumatic Edition by Black &
pneumothorax as a
Hawks
result into the pleural
space and the Brunner and
accumulation of air
Suddarth’s Textbook
and fluid in the
of Medical-Surgical
pleura space.
Nursing 2004 10th
Retained secretions Edition by Smeltzer &
are a threat to the Bare
thoracotomy patient
after surgery. Nursing Care Plans
Trauma to the 2007 6th Edition
tracheobronchial tree Gulanick/Myers
during surgery and
diminished lung
ventilation all result
in the accumulation
of excessive
secretions. If the
secretions are
retained obstruction
of airway occurs.
This in turn causes
the air in the alveoli
distal to the
obstruction to
become absorbed in
the affective portion
of the lung to
collapse.
Sources:
Doenges M. et. Al.
11th ed. Nurses
pocket guide.

Smeltzer S.C. Bare B.


G. 10th ed. Medical
surgical nursing Vol.
2

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