Nursing Care Plan

< Return to Care Plan Listing

Medical Diagnoses: Pneumothorax, COPD, Emphysema, Malnutrition, Alzheimers, Dementia, Atrial Fibrillation !!! (Mam Eto Yung sa Hirap ng paghinga ung sa baba naman Constipation naman ung problema dun) !!!
Assessment Nursing DX/Clinical Problem Client Goals/Desired Outcomes/Objecti ves Long Term: Client will demonstrate improved ventilation and adequate oxygenation as evidenced by blood gas levels within normal parameters for this client by 09:00, 2/23/09. Nursing Interventions/Actions /Orders and Rationale -Assess nutritional status including serum albumin level and body mass index. Weight loss in a client with COPD ha a negative effect on the course of the disease; resulting in a loss of muscle mass and in the respiratory muscles which can lead to respiratory failure (Celli & MacNee, 2004). -Help the client eat small frequent meals and use dietary supplements as necessary. Having a BMI less than 21 has been associated with earlier mortality in patients with COPD (Schols et. al, 1995) -monitor patients blood gas levels -Monitor respiratory rate, depth and effort. -Monitor clients behavior and mental status for the onset of restlessness. Changes

* I *

Evaluation Goals Evaluation of this goal is set for 22:00, [Month] 23, [Year]. Reminders to breathe through his nose improved pulse oximetry measurements of saturation. Some progress made towards goal. Interventions Clients serum albumin is low and the BMI is 16.2. Assessment complete, continued monitoring required. Help client eat sorbet, administered nutritional supplements. Intervention achieved today, continuation required. Blood gas levels not drawn, this intervention not achieved, reevaluation set for 22:00, [Month] 23, [Year].

Subjective: Client verbalized statements indicative of confusion. Objective: Client has a chest tube to treat a pneumothorax. Client has an increased AP diameter. Client was breathing through his mouth and not his nose (which had a nasal cannula). O2 saturation was in the 80s while patient was mouthbreathing and in the 90s while nasal breathing. Client had an abnormal breathing pattern, restlessness, and visual disturbances.

Problem: Impaired gas exchange

R/T: Alveolar-capillary membrane changes and ventilationperfusion imbalance

Short Term: Client will maintain clear lung fields and remain free of signs of

* Clients lung fields were

clear to auscultation and client was calm and free of signs of respiratory distress by 12:30, [Month] 17, [Year].

Monitored clients respiratory rate, depth, effort, behavioral and mental status. Monitored clients pulse oximetry and cued client to breathe

AEB: Pulse oximetry below 90%, barrel chest, restlessness, confusion, visual disturbances (hallucinations), abnormal breathing pattern.

respiratory distress by 12:30, 2/17/09.

in a clients mental status can be an early sign of impaired gas exchange (Simmons & Simmons, 2004). -Monitor clients oxygen saturation continuously by pulse oximetry. The goal of inpatient therapy for the client with COPD is to maintain the oxygen saturation greater than 90% and PaO2 at or above 80 mm Hg to maintain cellular oxygen (Celli & MacNee, 2004) -Position client in the semi-Fowlers position. Research indicates that the 45 degree position facilitates breathing and reduces the risk of pneumonia (Speelberg & Van Beers, 2003). -Remind the client to breathe through his nose and not his mouth

through nose when SaO2 dropped below 90%. Positioned client in the semi-Fowlers position to facilitate breathing. Clients SaO2 and calm demeanor indicative of no respiratory distress, interventions successful.

*I = Implementation. Check those interventions/actions/orders that were implemented.

Nursing Care Plan Medical Diagnoses: Pneumothorax, COPD, Emphysema, Malnutrition, Alzheimers, Dementia, Atrial Fibrillation
Assessment Subjective: Client not hungry, turns away from food, spits it out, expressed confusion regarding where he was . Objective: Client has developed urinary incontinence, hyperactive bowel sounds upon auscultation, change in bowel pattern, unable to pass stool, and no BM within the past 7 days, and has a serum K+ and Ca+ level that are low. Nursing DX/Clinical Problem Problem: Constipation Client Goals/Desired Outcomes/Objectives Long Term: Client will maintain passage of soft, formed stool every 1-3 days without straining by 12:00, [Month] 19, [Year]. Nursing Interventions/Actions/ Orders and Rationale -Promote regular consistent toileting each day based on the client's triggering meal. Safeguard the client's visual and auditory privacy when toileting (AHRQ, 2005)

*I *

Evaluation Goals Evaluation of this goal is set for 17:00, [Month] 23, [Year]. No progress made. Interventions Evaluation of this intervention is set for 17:00, [Month] 23, [Year]. Intervention unsuccessful to date. Further evaluation required.

R/T: Inadequate toileting, insufficient physical activity, mental confusion, calcium carbonate supplements, and electrolyte imbalance.

Short Term: Client will have a bowel movement within 6 hour shift on [Month] 17, [Year].

AEB: Patient self-assessment of pain rated an 8 on a scale 0f 0-8, generalized pallor, selfreport of nausea r/t pain quality, restlessness, and distractibility.

-Assess clients bowel hx, determine date of last bowel movement -Palpate for abdominal distention, auscultated for bowel sounds. In clients with constipation, the abdomen is often distended and tender, bowel sounds are present (Hinrichs, et al, 2001) -Provide laxatives, stool softeners and enema as ordered -When giving soap suds enema, measure the amount of fluid given and the amount expelled. Enema fluid can be retained and damage epithelium (Hinrichs, Huseboe, & Tang, 2001)

Client did not have a bowel movement. Goal not achieved. Further assessment required to facilitate achievement of the goal.

Assessed clients bowel movement history, palpated for abdominal distention (none present), and auscultated bowel sounds (hyperactive). No tenderness noted. Provided laxative, stool softener and enema as ordered. Measured amount instilled, estimated amount expelled. Interventions achieved but were unsuccessful. Further assessment required to reevaluate interventions utilized and whether they meet the underlying issue.

Another Article Next Page:

NCP: Impaired Gas Exchange r/t alveoli obstruction as evidence by dyspnea, reduced activity tolerance secondary to pulmonary emphysema
Written by admin Nursing Care Plan's Feb 26, 2011 Cues Subjective: He has a difficulty in breathing sometimes. as verbalized by the watcher. Objective: Vital Signs: BP: 150/90 Temp.: 36.9 CR: 72 PR: 70 RR: 26 - ABG result as of (Date) pH: 7.46 (H) PC02: 32.5 Terr(L) PO2: 78.2 Terr(L) HC03: 23.2meq/L +C02: 24.2 B-E: 0.7 - reduced activity tolerance - use of accessory muscle during respiration Need ACTIVITY EXERCISE PATTERN Diagnosis Impaired Gas Exchange related to alveoli obstruction as evidence by dyspnea, reduced activity tolerance secondary to pulmonary emphysema. Emphysema begins with the destruction of alveolar septa, which eliminates portions of the pulmonary capillary bed and increases the volume of air in the acinus. Thus, the balance is tipped toward alveolar destruction and loss of normal elastic recoil of the bronchi. Objectives

That within our 8 hours span of care our patient will be able to: a) demonstrate improved ventilation and adequate oxygenation. b) verbalize understanding of causative factors and appropriate interventions. c) participate in treatment regimen within level of ability. Interventions 1. Assess respiratory rate, depth, use of accessory muscle. R: useful in evaluating the degree of respiratory distress. 2. Auscultate breath sounds, noting areas of decreased airflow and /or adventitious sounds. R: breath sounds may be faint because of decreased airflow or areas of consolidation. 3. Palpate for fremitus R: decrease of vibratory tremors suggests fluid collection or air trapping 4. Elevate head of the bed/ position client appropriately. R: to maintain airways. 5. Monitor vital signs and cardiac rhythm. R: tachycardia, and changes is BP can reflect effect of systemic hypoxemia on cardiac function. 6. Encourage frequent position changes and deep breathing/coughing exercise. R: Promotes proximal chest expansion and drainage of secretions. 7. Encourage to have adequate sleep. Provide a peaceful environment. R: helps limit oxygen consumption. 8. State the causative factors of such illness. R: To inform the appropriate procedures to be done in order to have proper ventilation. Evaluation After my 8 hours span of care our patient was able to: a) demonstrate improved ventilation and adequate oxygenation by manifesting vital signs are within normal range. BP: 130/80 RR: 20 b) anticipate in treatment regimen by compliance of medicines.

HAP-COPD
Nursing Care Plan Pneumonia
3Share 0digg PNEUMONIA I. Pathophysiology a. Inflammation of the lung parenchyma associated with alveolar edema and congestion that impairs gas exchange b. Common pathogens i. Viruses 1. Common causative organisms include respiratory syncytial virus (RSV) and influenza 2. Accounts for approximately half of all cases of community-acquired pneumonia (CAP) ii. Bacteria 1. Divided into typical and atypical types 2. Gram-positive Streptococcus pneumoniae, Haemophilus, and Staphylococcus most common bacterial causes iii. Fungus 1. Most common causes Histoplasma capsulatum and Coccidioides immitis 2. Pneumocystis carinii and cytomegalovirus (CMV) often occur in immunocompromised persons iv. Other 1. Agents include Mycoplasma, Mycobacterium tuberculosis, Coxiella burnetii, Chlamydia, and Legionella II. Classification a. Site and causative agent i. Lobar, single lobe; broncho, smaller lung areas in several lobes; interstitial, tissues surrounding the alveoli and bronchi ii. Bacteria, viruses, and fungi b. Distribution

i. CAP commonly caused by S. pneumoniae, Chlamydia pneumoniae, Haemophilus influenzae, RSV, occasionally atypical pathogens ii. Nosocomial develops at least 48 hours after admission to an institution or care center; hospital-acquired pneumonia (HAP) and/or ventilator-associated pneumonia (VAP) is often caused by Pseudomonas aeruginosa, Klebsiella pneumoniae, Staphylococcus aureus, and both methicillinsensitive and methicillin-resistant S. aureus (MRSA) III. Etiology a. Primary pneumonia is caused by the clients inhalation or aspiration of a pathogen (microaspiration). b. Secondary pneumonia ensues from lung damage caused by the spread of an infectious agentbacterial, viral, or fungalfrom another site in the body or from various chemical irritants (including gastric reflux and aspiration, smoke inhalation) or radiation therapy. c. Risk factors: comorbidities, such as heart or lung disease, compromised immune system, diabetes mellitus, liver or renal failure, malnutrition, smoking, over age 70, previous antibiotic therapy, abdominal or thoracic surgical procedures, endotracheal intubation with mechanical ventilation IV. Statistics (American Lung Association, 2007c; National Center for Health Statistics [NCHS], 2007; National Heart, Lung and Blood Institute [NHLBI], 2008a) a. Morbidity: An estimated 6 million cases are reported annually; hospital discharges attributed to pneumonia in 2005 were 651,000 males (44.9 per 10,000) and 717,000 females (47.7 per 10,000). b. Mortality: Approximately 58,000 deaths per year; eighth leading cause of death in the United States (pneumonia and influenza combined, with pneumonia the leading cause); accounts for approximately 10% of all inpatient deaths. c. Cost: Estimated annual cost is $8.4 billion for CAP (Lutfiyya, 2006); in excess of $1 billion per year for HAPs; up to $20,000 to $29,000 per episode of VAP, with length of stay increased by as much as 14 days (Niederman, 2001; Schleder, 2004). Care Setting

Most clients are treated as outpatients in community settings; however, persons at higher risk, such as those older than 65 and persons with other chronic conditions such as chronic obstructive pulmonary disease (COPD), diabetes, cancer, and congestive heart failure, are treated in the hospital, as are those already hospitalized for other reasons and who have developed nosocomial pneumonia. NURSING DIAGNOSIS: ineffective Airway Clearance May be related to Tracheal bronchial inflammation, edema formation, increased sputum production Pleuritic pain Decreased energy, fatigue Possibly evidenced by Changes in rate, depth of respirations Abnormal breath sounds, use of accessory muscles Dyspnea, cyanosis Cough, effective or ineffective; with or without sputum production Desired Outcomes/Evaluation CriteriaClient Will Respiratory Status: Airway Patency Identify and demonstrate behaviors to achieve airway clearance. Display patent airway with breath sounds clearing and absence of dyspnea and cyanosis. Nursing Priorities 1. Maintain or improve respiratory function. 2. Prevent complications. 3. Support recuperative process. 4. Provide information about disease process, prognosis, and treatment. Discharge Goals 1. Ventilation and oxygenation adequate for individual needs. 2. Complications prevented or minimized. 3. Disease process, prognosis, and therapeutic regimen understood. 4. Lifestyle changes identified and initiated to prevent recurrence. 5. Plan in place to meet needs after discharge. ACTIONS/INTERVENTIONS Airway Management Independent Assess rate and depth of respirations and chest movement. Monitor for signs of respiratory failure; for example, cyanosis and severe tachypnea.

Auscultate lung fields, noting areas of decreased or absent airflow and adventitious breath sounds, such as crackles and wheezes. Elevate head of bed; change position frequently. Assist client with frequent deep-breathing exercises. Demonstrate and help client, as needed; learn to perform activity, such as splinting chest and effective coughing while in upright position. Suction, as indicated; for example, oxygen desaturation related to airway secretions. Force fluids to at least 2,500 mL per day, unless contraindicated, as in HF. Offer warm, rather than cold, fluids. Collaborative Assist with and monitor effects of nebulizer treatments and other respiratory physiotherapy, such as incentive spirometer, intermittent positive-pressure breathing (IPPB), percussion, and postural drainage. Perform treatments between meals and limit fluids when appropriate. Administer medications, as indicated, for example mucolytics, expectorants, bronchodilators, and analgesics. Provide supplemental fluids such as IV, humidified oxygen, and room humidification. Monitor serial chest x-rays, ABGs, and pulse oximetry readings. (Refer to ND: impaired Gas Exchange, following.) RATIONALE Tachypnea, shallow respirations, and asymmetric chest movement are frequently present because of discomfort of moving chest wall or fluid in lung. When pneumonia is severe, the client may require endotracheal intubation and mechanical ventilation to keep airways clear. Decreased airflow occurs in areas consolidated with fluid. Bronchial breath sounds (normal over bronchus) can also occur in consolidated areas. Crackles, rhonchi, and wheezes are heard on inspiration and expiration in response to fluid accumulation, thick secretions, and airway spasm or obstruction. Keeping the head elevated lowers diaphragm, promoting chest expansion, aeration of lung segments, and mobilization and expectoration of secretions to keep the airway clear. Deep breathing facilitates maximum expansion of the lungs and smaller airways. Coughing is a natural self-cleaning mechanism, assisting the cilia to maintain patent airways. Splinting reduces chest discomfort, and an upright position

favors deeper, more forceful cough effort. Note: Cough associated with pneumonias may last days, weeks, or even months. Stimulates cough or mechanically clears airway in client who is unable to do so because of ineffective cough or decreased level of consciousness. Fluids, especially warm liquids, aid in mobilization and expectoration of secretions. Facilitates liquefaction and removal of secretions. Postural drainage may not be effective in interstitial pneumonias or those causing alveolar exudates or destruction. Coordination of treatments, schedules, and oral intake reduces likelihood of vomiting with coughing and expectorations. Aids in reduction of bronchospasm and mobilization of secretions. Analgesics are given to improve cough effort by reducing discomfort, but should be used cautiously because they can decrease cough effort and depress respirations. Fluids are required to replace losses, including insensible, and aid in mobilization of secretions. Note: Some studies indicate that room humidification has been found to provide minimal benefit and is thought to increase the risk of transmitting infection. Follows progress and effects of disease process and therapeutic regimen, and facilitates necessary alterations in therapy.