Nursing Care Plan

ASSESSMENT DIAGNOSIS
ASSESSMENT DIAGNOSIS PLANNINGPLANNINGINTERVENTION
INTERVENTION RATIONALE
RATIONALE EVALUATION
EVALUATION
S – “May tubo po Risk for • At the end • Observe for • To assess • At 8 hours of
ako sa tagiliran,
S – “Nahihirapan Infection
Ineffective related
• At the end of ofIndependent:
the shift, localized signs of causative/ series nursing
• After the
akongmay apat na araw
huminga”, Airway to inadequatethe shift, the the client
• Assist patient to infections
assume at • Elevation of contributing
the head of the interventions,
shift, the
na,”as verbalized
as verbalized by primary defense
Clearance client will will insertion
position of comfort, eg., sites. factors.
bed facilitates respiratory the client
client was
by the patient. related toas evidenceddemonstrate
the patient. by demonstrate
elevate head• ofNote
bed, risk factors forfunction by use of gravity. demonstrated
able to
increased
chest tube behaviors to techniques,
encourage patient to lean of
occurrence demonstrate
techniques,
O– production of
intubation. improve lifestyle on the over bedinfection.
table or Eg., behaviors to
lifestyle
O- • Pain on thesecretions. airway changes tosit on the edge of the • Precipitation of allergic type improve
changes to
extremes of age,
• use ofinsertion clearance. promote bed. or respiratory reactions that airway
promote safe
immunocompromis
accessory E.g., cough • Keep environmental can trigger or exacerbate clearance eg.,
site of the safe ed host, skin/ tissue environment.
muscle effectively and pollution to a minimum, onsets of acute episodes. cough
tube with environment wounds,
• dyspnea expectorate e.g. dust, smoke, and • Provide patient with some effectively
pain scale .
• productiv secretions. feather pillows,communities or means of coping or control and
e of 5/ 10 persons sharing
according to individual dyspnea and reduce air expectorate
• With slight
cough situation. rooms or quarters trapping. secretions.
• (+) night body and
• Encourage or assist with/ or equipment,
• Coughing is most effective in
sweatsweakness accidental or
pursed lip breathing an upright position or head
• (+) • pallor
Irritable exercises. intentional down position after chest
• Restless
• Irritable • Observe characteristics
environmental percussion.
• Restless
• With vital of cough line persistent
exposure.
or hacking•or moist.
Note signs and
signs of
Assist with measures
symptoms • A variety of medications may
to of sepsis
BP – 110/80 improve effectiveness of be used to decrease mucus
TEMP - 37◦C (systemic
cough effort. and to improve respiration.
RR – 19 bpm infection), fever,
Dependent: • Humidity helps reduce
PR – 75 b/m chills.
• Administer medication as viscosity of secretions,
• • To reduce/
Stress proper hand facilitating
prescribed by the expectoration and
physician. hygiene between correct
may reduce or prevent
therapist and
• Provide supplemental formation ofexisting risk
thick mucus
humidification line plugs in bronchioles.
nebulizer.
 clients. factors
• Monitor client’s • To limit
visitors for exposures,
respiratory thus reduce
illnesses. cross-
contaminati
• Review individual on.
nutritional needs, • To promote
appropriate exercise wellness
program and need (teaching
for rest. discharge
• Instruct client in consideratio
techniques to n)
protect the integrity
of skin, care for
lesions, and
prevention of the
spread of
infections.
• Emphasize • Premature
necessity of taking discontinuat
anti- virals / ion of
antibiotics as treatment
directed (eg. Doses when client
and length of begins to
therapy ) feel well
may result
in return of
infection
and
potentiate
drug
resistant
strains.