Nursing Care Plan

NURSING ANALYSIS
GOAL/ INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
OBJECTIVES
Nsg. Dx: Ineffective After 1 week of
airway clearance r/t nursing intervention,
neuromuscular Medical the client will After nursing
dysfunction management of the maintain patent intervention the
clients with stroke is airway. patient maintain
Subjective Cues: directed at early effective airway
diagnosis and early 1. After nursing  Auscultate breath Provides baseline for clearance as
The client’s daughter identification of the interventions, the sounds. Note patient care. evidenced by clear
verbalized: client who can client’s airway adventitious breath sounds,
>”nakahiga lang benefit from patency will be breath sounds, normal respirations,
sya,naghihina kc c thrombolytic assessed. e.g., wheezes, and effective cough.
mommy” treatment. crackles, rhonchi.
>”din na siya Preserving cerebral  Assess/monitor
makapagsalita, oxygenation, respiratory rate.
umuungol na lang preventing Note
kapag sumasagot” complications and inspiratory/expirat
>”itong kaliwang stroke recurrence, ory ratio.
bahagi lang yung and rehabilitating the
naigagalaw niya” client are other 2. After nursing  Suction patient Patients who are
>”nahihirapan siyang goals. interventions, the every 2-4 hours immobile and
huminga kya nilagyan Emergency care client’s secretions and prn, being unconscious have
nito(referring to of the client with will be readily sure to hyper- ineffective cough
tracheostomy)” stroke includes expectorated. oxygenate patient reflexes thus
maintaining a patent prior to, during, suctioning is
Objective Cues: airway. The client and after required to remove
should be turned on procedure; limit secretions.
>left face and the affected side if active suctioning Suctioning time
extremities are he or she is to 15 seconds to should be minimized
paralyzed unconscious to less at a time. and hyper-
>presence of NGT promote drainage of oxygenation
>on O2 therapy saliva from the performed to reduce
>presence of airway. Clients with the potential for
secretions in the mouth stroke are at high hypoxia.
risk for aspiration
pneumonia, which is
the direct cause of 3. After nursing  Position the High-Fowler’s or
death in 6% of intervention, the patient in high- semi-fowler’s
BP: 180 / 90 mmHg clients with stroke. client will be Fowler’s or semi- position promotes
RR: 19 cpm aspiration is most positioned fowler’s position if maximal lung
PR: 65 bpm common in the early comfortably with not expansion.
Temp: 36.6 °C period and is related maximum lung contraindicated.
to lost of pharyngeal expansion.
sensation , loss of
oropharyngeal motor 4. After nursing Turn patient every 2 Repositioning