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Word Ncp.......... Tetanus

The document describes a patient who is having difficulty opening their mouth. The objective findings include trismus and oral secretions. The diagnosis is risk of aspiration related to impaired swallowing. The plan is for the patient to learn techniques to prevent aspiration after nursing interventions. Interventions include assessing factors for aspiration, suctioning secretions, elevating the head of bed, and providing fluids in an elevated position. The expected outcome is preventing aspiration.

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aianr
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523 views6 pages

Word Ncp.......... Tetanus

The document describes a patient who is having difficulty opening their mouth. The objective findings include trismus and oral secretions. The diagnosis is risk of aspiration related to impaired swallowing. The plan is for the patient to learn techniques to prevent aspiration after nursing interventions. Interventions include assessing factors for aspiration, suctioning secretions, elevating the head of bed, and providing fluids in an elevated position. The expected outcome is preventing aspiration.

Uploaded by

aianr
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
Download as doc, pdf, or txt
Download as doc, pdf, or txt
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ASSESSMENT SUBJECT: Nahihirapan akong lumumod As verbalized by the patient OBJECTIVE: With trismus with of presence of oral mucous

us secretions With presence of dysphagia

DIAGNOSIS Risk for aspirations related to impaired swallowing

PLANNING After continuous nursing intervention patient will be able to demonstrate techniques to prevent aspiration

INTERVENTION Assess factors that might lead to aspiration ( presence of dysphagia) Assess amount and consistency of secretions Maintatin operational suction equipment at bedside Suction as needed to clear secretions Elevate head of bed when providing fluids

RATIONALE To know causative or contributing factor

EVALUATION Expected Outcome: Goal met >seen patient in elevated positiona

To assist in correcting factors that can lead to aspiration To clear secretions To facilitate clearing airway

Avoid nonstimulating To and quiet pRevent stimulation environment

Provide warm or liquid

very cold

To activates temp receptors in the mouth that helps to stimulate swallowing For exercise that may strengthen muscles to enhance swalowing To promote wellness

Refer to speech therapist

Encouraged to strictly adhere to treatment regimen

ASSESSMENT Subjective: sumasakit ang panga ko As verbalized by the patient Objective: With facial grimace with pain score of 5 out of 10 >slightly irritated Slightly diaphoretic >With trismus noted with abdominal rigidity

DIAGNOSIS Acute Pain related to uncontrolled muscle spasm and involuntary muscle contraction

PLANNING After 2 hours of nursing intervention patients pain Will be relieved and controlled.

INTERVENTION Assess predisposing factors to pain

RATIONALE To know the etiology of pain

EVALUATION Patients pain score 0f 5 decreased to 2 ( moderate to mild pain) seenS patient comfortably sleeping

Monitor vital signs Usually altered in acute pain Ask the patient to describe the pain Encourage verbalization of feelings Encourage to have diversional activities Adviced to have comfort measures sucha s back rub To determine how in pain the patient is.

To divert the attention of the patient while in pain To provide non pharmacological pain management

Administer

ASSESSMENT SUBJ: nahihirapan akong huminga as verbalized by the patient. OBJ: With difficulty vocalizing words >with trismus noted occassionally >Slighly cyanotic >with rapid and shallow breathing >Fast breathing- 35bpm >with oral mucous secretions

DIAGNOSIS ineffective Airway Clearance related to airway spasm and neuromuscular dysfunction

PLANNING After 2 hours of nursing intervention, patient will be able to maintain airway patency

INTERVENTION Position the client appropriately by elevating of head bed encourage deep breathing exercise

RATIONALE For maximum lung expansion To maximize effort and mobilized secretions

EVALUATION Goal met. Patient was able to maintain adequate airway patency as avidenced by stabilized Respiratory rate of 21 bpm

Monitor respirations and breath sounds Position the patient by elevating the bed Insert oral airway in severe cases as ordered

To assess changes and note complications

To maintain anatomic position of tongue and natural airway

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