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    Nursing Care Plan: Assessm ENT Nursing Diagnos IS Planning Intervention Rationale Evaluati ON Subjectiv e

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    J. TS
    The patient presented with a 2-week history of chest cold symptoms including shortness of breath and elevated temperature. On examination, inspiratory crackles were heard in the right lung. The nursing diagnosis was ineffective airway clearance related to accumulated mucus obstructing the airway. Short-term goals were for the patient to be able to classify methods to enhance secretion removal and maintain a clear airway. Long-term goals were for the patient to independently maintain a clear airway. Planned interventions included monitoring respiration, encouraging hydration, positioning, teaching coughing and breathing techniques, administering medications, performing suctioning, educating on self-care, and coordinating with other providers. The evaluation

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    Nursing Care Plan: Assessm ENT Nursing Diagnos IS Planning Intervention Rationale Evaluati ON Subjectiv e

    Uploaded by

    J. TS
    94 views4 pages
    The patient presented with a 2-week history of chest cold symptoms including shortness of breath and elevated temperature. On examination, inspiratory crackles were heard in the right lung. The nursing diagnosis was ineffective airway clearance related to accumulated mucus obstructing the airway. Short-term goals were for the patient to be able to classify methods to enhance secretion removal and maintain a clear airway. Long-term goals were for the patient to independently maintain a clear airway. Planned interventions included monitoring respiration, encouraging hydration, positioning, teaching coughing and breathing techniques, administering medications, performing suctioning, educating on self-care, and coordinating with other providers. The evaluation

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    The patient presented with a 2-week history of chest cold symptoms including shortness of breath and elevated temperature. On examination, inspiratory crackles were heard in the right lung. The nursing diagnosis was ineffective airway clearance related to accumulated mucus obstructing the airway. Short-term goals were for the patient to be able to classify methods to enhance secretion removal and maintain a clear airway. Long-term goals were for the patient to independently maintain a clear airway. Planned interventions included monitoring respiration, encouraging hydration, positioning, teaching coughing and breathing techniques, administering medications, performing suctioning, educating on self-care, and coordinating with other providers. The evaluation

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    94 views4 pages

    Nursing Care Plan: Assessm ENT Nursing Diagnos IS Planning Intervention Rationale Evaluati ON Subjectiv e

    Uploaded by

    J. TS
    The patient presented with a 2-week history of chest cold symptoms including shortness of breath and elevated temperature. On examination, inspiratory crackles were heard in the right lung. The nursing diagnosis was ineffective airway clearance related to accumulated mucus obstructing the airway. Short-term goals were for the patient to be able to classify methods to enhance secretion removal and maintain a clear airway. Long-term goals were for the patient to independently maintain a clear airway. Planned interventions included monitoring respiration, encouraging hydration, positioning, teaching coughing and breathing techniques, administering medications, performing suctioning, educating on self-care, and coordinating with other providers. The evaluation

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    NURSING CARE PLAN

    ASSESSM NURSING PLANNING INTERVENTION RATIONALE EVALUATI


    ENT DIAGNOS ON
    IS
    Subjectiv Ineffectiv After 1 week Independent: Independent Long
    e e airway of nursing - Monitor - First and Term
    “chest clearance intervention and/or foremost,
    cold” for 2 related to ,the patient assess the the airway Goal Met
    weeks ; accumula will be able respiration must always
    shortness ted to; and airway be kept After 1
    of breath mucus Long Term: patency open, week of
    upon obstructi -The patient - Encourage particularly nursing
    exertion; ng the will be able hydration in situations interventi
    elevated airway to maintain at least 8 involving ons, the
    temperat clear, open glasses of trauma, patient
    ure airways as water/day rapid was able
    “pain” in evidence by - Position cerebral to
    her normal head decompens maintain
    “lungs.” breath appropriat ation, or clear,
    sounds, e for cardiac open
    Objective normal rate condition arrest. airways as
    s and depth such as - To loosen evidence
    •inspirato of fowler’s secretion by normal
    ry crackles respiration. position - To keep an breath
    with - Teach the individual’s sounds,
    diminishe patient airway open normal
    d breath After 3 Days how to while they rate and
    sounds in of nursing breathe are at rest depth of
    the right intervention and cough or in a respiratio
    lung , the patient correctly. compromis n.
    will be able (For ed state.
    to; example, -Coughing is
    Short inhale the most Short
    Term: deeply, practical Term
    -The patient hold it for approach to
    will be able two get rid of Goal Met
    to classify seconds, most
    methods to and then secretions. After 3
    enhance cough Therefore, days of
    secretion twice or helping the nursing
    removal as three patient with interventi
    evidence by times in this task is ons, the
    ability to quick essential. patient
    effectively succession Contrarily, was able
    cough up ). deep to classify
    secretions Dependent: breathing methods
    after - Give encourages to
    treatments medication oxygenation enhance
    and deep s as prior to secretion
    breaths. prescribed, deliberate removal
    such as coughing. as
    antibiotics, evidence
    mucolytic Dependent: by ability
    agents, - Different to
    bronchodil drugs are effectively
    ators, prepared to cough up
    expectora address secretions
    nts, noting different after
    effectivene issues. Most treatment
    ss and side encourage s and deep
    effects. the removal breaths.
    - Perform of
    nasotrache secretions
    al from the
    suctioning airways and
    as may lessen
    necessary, airway
    especially resistance.
    if cough is - When
    ineffective. patients are
    - Educate weak, have
    patient on thick mucus
    coughing, plugs in
    deep their
    breathing, throats, or
    and produce a
    splinting lot of
    techniques persistent
    . mucus, they
    need to be
    Collaborative suctioned.
    - The patient
    - Find out if will
    the patient comprehen
    is thinking d the
    about fundamenta
    using l idea and
    herbal the
    remedies appropriate
    (e.g., ma methods for
    huang for maintaining
    bronchosp a secretion-
    asm, free airway.
    goldenseal Collaborative
    for - It is
    pneumoni necessary
    a, and to consider
    echinacea drug
    for URTIs). interactions
    - Coordinate with
    with a prescription
    respiratory drugs and
    therapist contraindic
    for chest ations.
    physiother - Postural
    apy and drainage
    nebulizer and chest
    manageme percussion
    nt as are two
    indicated. methods
    - Teach used in
    caregivers chest
    proper physiothera
    suctioning py to
    methods. mobilize
    Offer a secretions
    chance for from tiny
    a follow- airways that
    up cannot be
    demonstra removed
    tion. Adapt with suction
    methods or
    for a coughing.
    domestic - This
    environme facilitates
    nt. the efficient
    and safe
    clearance of
    secretions
    from the
    airway..

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