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NURSING CARE PLAN

CUES NURSING DIAGNOSIS RATIONALE GOAL NURSING INTERVENTIONS RATIONALE EVALUATION

Subjective: Ineffective airway Chronic cough and After 8 hours of nursing  Independent: After 8hrs of nursing
clearance r/t sputum production interventions the client 1. Position the client in an upright 1. An upright or semi-Fowler’s intervention, Goal
The patient increased production often precede the will be able to: or semi-Fowler’s position. position facilitates in lung partially met:
verbalizes of thick and viscous development of 1. Demonstrate expansion.
“Nabudlayan ako secretions airflow limitation. effective coughing Client demonstrates
mag ginhawa.” The mucus- and clear breath 2. Encourage to take in fluids and 2. This liquefies secretions for effective coughing
producing bronchial sounds. promote hydration. easy expectoration. as evidenced by
Objective: wall hypertrophy 2. Maintain patent expectoration of
and increased in airway at all times. 3. Using touch on the shoulder, 3. The nurses’ presence, secretions.
> RR- number 3. Relate methods to coach the client to slow reassurance, and help in Crackles and
23bpm(slightly Definition: consequently the enhance secretion respiratory rate demonstrating controlling the client’s wheezing were
tachypneic) A state in which an increase mucus removal. slow respirations; making eye breathing can be very decreased in all lung
> Abnormal individual is unable secretions affect the 4. Identify and avoid contact with the client; and beneficial in decreasing fields.
breathe sounds to clear secretions flow of air and specific factors that communicating in a calm, anxiety. The client was able
(wheeze, from respiratory tract exchange of gas inhibit effective supportive fashion. to breathe with ease
crackles) to maintain airway and may airway clearance. as evidenced by a
> Cough with patency. predispose the 4. Note pattern of respiration. 4. Symptoms may be masked decreased in
sputum client to plugging by chronic respiratory respiratory rate from
and infection. Long conditions common among 23 to 20 breath per
> Decrease
Reference: standing infection older adults. minute.
respiratory
results in
excursion.
Nurses’ Pocket destruction of lung 5. Monitor respiratory rate, depth, 5. Understanding the
Guide tissue. With and ease of respiration. underlying cause of
By: Doenges,Marilyn infection, the patient’s particular
4th edition page 67 amount of sputum ventilatory problem is
becomes more essential to the care of
copious and patient
purulent.
Breathlessness on 6. Note abdominal breathing, use 6. These symptoms signal
exertion occurs with of accessory muscles, nasal increasing respiratory
increasing severity. flaring, retractions, irritability, difficulty and increasing
confusion, or lethargy. hypoxia.
• Collaborative:
1. Administer medications as 1.
indicated:
> Salbutamol(Ventolin) > This drug relaxes bronchial
through nebulization and
> This relaxes smooth muscles
> Theophylline(Asmasolo of the bronchial tree and
n) pulmonary blood vessels.
CNS stimulation(including
the respiratory center)

> This drug stimulates beta-


receptors thus producing
> Bambuterol(Bambec) relaxation of bronchial
smooth muscles.

2. To facilitate the
demand of oxygen in
2. Administer O2 inhalation 2lpm the body. And help in
via nasal cannula. dyspnea.
NURSING CARE PLAN
CUES NURSING DIAGNOSIS RATIONALE GOAL NURSING INTERVENTIONS RATIONALE EVALUATION
• Independent
1. Ascertain patient’s beverage
preferences, and set up a 24-
hr schedule for fluid intake.
Encourage foods with high 1. Relieves thirst and discomfort
fluid content. of dry mucous membranes and
augments parenteral
2. Monitor urinary output. replacement.
Measure/estimate fluid losses
from all sources.
2. Fluid replacement needs are
After 8 hours of
based on correction of current
nursing interventions
deficits and ongoing losses. A
the client will be able
decreased urinary output may
to:
indicate insufficient renal
1. Maintain fluid
perfusion/hypovolemia, or
volume at a
polyuria can be present,
functional level.
3. Monitor for sudden/marked requiring more aggressive fluid
2. Verbalize
elevation of BP, restlessness, replacement.
understanding of
moist cough, dyspnea, basalar
causative factors
Fluid volume crackles, frothy sputum. 3. Too rapid a correction of fluid
FVD results from loss and purpose of
deficit r/t Diarrhea deficit may compromise the After 8 hours of
of body fluid intake. therapeutic
cardiopulmonary system, nursing
FVD can develop from intervention.
4. Weigh daily and compare with especially if colloids are used in interventions Goal
Subjective: inadequate intake 3. Demonstrate
24-hr fluid balance. general fluid replacement. partially met:
alone if the decreased behaviors
Mark/measure edematous • Maintain fluid
The patient intake is prolonged. participate and
areas, e.g., abdomen, limbs. 4. Although weight gain and fluid volume at a
verbalizes “gatubig Cause of FVD includes correct fluid loss
intake greater than output may functional level
akon pamus-on.” abmormal fluid losses. as indicated.
not accurately reflect as evidenced
Such as, vomiting,
Definition: intravascular volume, e.g., third- by stable vital
Objective: nausea, diarrhea,
The state in which space fluid accumulation cannot signs, moist
sweating or inability to
an individual be used by the body for tissue mucous
Hyperactive bowel gain access to fluid.
experiences perfusion, these measurements membranes,
sounds
vascular, cellular 5. Evaluate patient’s ability to provide useful data for good skin
Poor skin turgor
or intracellular swallow. comparison. turgor, and
Dry skin
deutoration (in prompt
Edema at the left leg
excess of needs 5. Impaired gag/swallow capillary refill.
and left forearm.
or replacement reflexes, anorexia/nausea, oral  Demonstrat
capabilities due to discomfort, and changes in level e behaviors
Sodium(129
failure of of consciousness/ to monitor
mmol/L)
regulatory cognition are among the factors and correct
mechanisms. 6. Provide skin and mouth care. that affect patient’s ability to deficit as
Creatine(137.02 appropriate.
Bathe every other day using replace fluids orally.
mmol/L)
mild soap. Apply lotion as
Reference: indicated. 6. Skin and mucous
membranes are dry, with
Nurses’ Pocket decreased elasticity, because of
Guide vasoconstriction and reduced
By: 7. Turn frequently, massage skin, intracellular water. Daily bathing
Doenges,Marilyn and protect bony prominences. may increase dryness.
th
Filamer Christian College
College of Nursing
Roxas City

DRUG STUDY

Name of Patient: L. M. Age/Sex: 78 years old , male Attending Physician: Dr. B______________
Area/Bed No.: _____________________________ Impression: _______________ Date: April 22, 2008_______________

Name of Drug Method of Mechanism of Action Adverse Reaction Special Consideration Nursing Responsibilities Rationale
Administration
Generic Name: Route: Relaxes bronchial and Bronchospasm, OccuNeb has not been 1. Monitor VS, measure 1. Expected clinical
enterine smooth muscle Hypersensitivity studied for treating acute and record effects include
Salbutamol Neb by acting on beta- reactions bronchospasms. intake/output. improvement in
adrenergic receptors quality of pulse
and respiration.
2. Warn patient of side 2. Dizziness is a
Brand Name: Timing: effects.(dizziness) common adverse
reaction at start of
Ventolin Stat therapy.

Classification: Dosage: Indications: Side Effects: Contraindications:


Relief of bronchospasm Tremor, nervousness, Patient with
Anti-asthma/ 1 neb in bronchial asthma, dizziness, insomnia, hypersensitivity to drug
Bronchodilator chronic bronchitis, headache, weakness, or its ingredients.
emphysema, obstructive tachycardia and irritated
pulmonary disease. nose and throat, nasal
Available forms: Frequency: congestion, nausea,
increased sputum, cough
Nebule muscle cramps.