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  • NCP Difficulty of Breathing R/T Secretion

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    The nursing care plan is for a 65-year-old male patient admitted with difficulty breathing diagnosed as pneumonia and/or edema. The plan lists the patient's subjective complaints and objective assessment findings, and outlines nursing interventions to improve respiration including monitoring breathing, positioning, encouraging deep breathing and ambulation, and administering ordered medications and oxygen. After 2 days of nursing care, the patient's difficulty breathing was relieved as evidenced by normalized vital signs and absence of dyspnea and other symptoms.

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    NCP Difficulty of Breathing r/t Secretion

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    The nursing care plan is for a 65-year-old male patient admitted with difficulty breathing diagnosed as pneumonia and/or edema. The plan lists the patient's subjective complaints and objective assessment findings, and outlines nursing interventions to improve respiration including monitoring breathing, positioning, encouraging deep breathing and ambulation, and administering ordered medications and oxygen. After 2 days of nursing care, the patient's difficulty breathing was relieved as evidenced by normalized vital signs and absence of dyspnea and other symptoms.

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    Attribution Non-Commercial (BY-NC)
    Téléchargez comme DOC, PDF, TXT ou lisez en ligne sur Scribd
    Signaler comme contenu inapproprié
    19K vues3 pages

    NCP Difficulty of Breathing R/T Secretion

    Transféré par

    herscentasiascribd
    The nursing care plan is for a 65-year-old male patient admitted with difficulty breathing diagnosed as pneumonia and/or edema. The plan lists the patient's subjective complaints and objective assessment findings, and outlines nursing interventions to improve respiration including monitoring breathing, positioning, encouraging deep breathing and ambulation, and administering ordered medications and oxygen. After 2 days of nursing care, the patient's difficulty breathing was relieved as evidenced by normalized vital signs and absence of dyspnea and other symptoms.

    Droits d'auteur :

    Attribution Non-Commercial (BY-NC)
    Téléchargez comme DOC, PDF, TXT ou lisez en ligne sur Scribd
    Signaler comme contenu inapproprié
    sur 3

    NURSING CARE PLAN

    Name of Patient:

    Age: 65 y/o Civil Status: Nationality: Occupation:

    Date of Admission: Chief Complaint/ Diagnosis: Difficulty of breathing Sex: Male

    PROBLEM/ HEAD
    SCIENTIFIC NURSING NURSING SCIENTIFIC
    CUES NURSING EVALUATION
    EXPLANATION OBJECTIVE INTERVENTION EXPLANATION
    DIAGNOSIS
    Subjective: Difficulty of breathing Among the most After 2 days of  monitored respiratory  With secretion in the After 2 days of
    “Sumasakit ang dibdib related to presence of common symptoms nursing patterns including rate, airway, the respiration nursing intervention,
    ko kapag humihinga” phlegm on the of lung disorders are interventions, the depth, and effort rate will increase. the patient respiration
    as verbalized by the tracheobronchial tree cough, dyspnea, and patient’s respiration  Auscultated breath  These abnormal lung has been improved
    patient. wheezing. Less shall have improved sounds noting sounds can indicate and difficulty of
    commonly, a and difficulty of decreased or absent pathology associated breathing has been
    Objective: blockage in the breathing shall have sounds, crackles, or with an altered relieved as
    airways between the been relieved. wheezing. breathing pattern. evidenced by:
     Dyspnea mouth and lungs  positioned the client to  An upright position
     Nasal flaring results in a gasping optimize respiration allows maximal lung  (-) dyspnea
    sound when expansion while lying  (-) nasal flaring
     Distended neck
    breathing. Problems flat on bed causes  (-) distended neck
    vein
    in the lungs can also abdominal organs to vein
     Wheezing
    lead to coughing up shift toward the chest,
     Chest pain  (-) wheezing
    of blood or which crowds the lungs
     Rapid and shallow  RR: 25 breaths/min
    hemoptysis, a bluish and makes it more
    breathing discoloration of the difficult to breath. Nursing objective
     V/S taken as skin due to a lack of  encouraged patient to  This technique can was met.
    follows: oxygen in the blood, perform deep help increase sputum
    RR: 32 breaths/min or chest pain. breathing clearance and
    PR: 80
    decrease cough
     XRAY (4/06/10) –
    spasm.
    Result: Fluffy
     encouraged  Immobility is often
    basal densities are
    ambulation as harmful to the elderly
    present
    tolerated without because it decreases
    Impression:
    causing exhaustion ventilation and
    Pneumonia and/or
    increases stasis of
    edema
    secretions, leading to
    atelectasis or
    pneumonia.
    PROBLEM/ HEAD
    SCIENTIFIC NURSING
    CUES NURSING NURSING INTERVENTION SCIENTIFIC EXPLANATION EVALUATION
    EXPLANATION OBJECTIVE
    DIAGNOSIS
     scheduled rest periods  Respiratory clients with
    before and after activity. dyspnea are easily
    exhausted and need
    additional rest.
     ensured adequate  The elderly are prone to
    hydration within cardiac dehydration and hydration
    and renal reserves helps decrease the
    viscosity of secretions,
    facilitating expectoration.
     assisted the client to  Awareness of precipitating
    identify other factors that factors helps the client
    can exacerbate or avoid them and decreases
    precipitate ineffective risk of ineffective breathing
    breathing episode patterns
     administered medication as  Treatment of patients with
    ordered acute and chronic
    bronchopulmonary
    diseases, rhinosinusitis,
    laryngopharyngitis or
    exacerbations of these
    chronic diseases in
    association with mucus
    production and transport.
     administer oxygen as  Oxygen has been shown
    ordered to correct hypoxemia,
    which can be caused by
    retained respiratory
    secretions.

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