Nursing Care Plan

Assessment Nursing Diagnosis Analysis Goal and objectives Interventions Rationale Evaluation

Interaction -The client's relative verbalized "Madalas siyang hingalin kahit pagdating sa magagaan na bagay" - The client verbalized "Nahirapan ako huminga" - The clients relative verbalized, Kahit ubo siya ng ubo hindi naman niya malilabaslaba s yung plema - The clients daughter

Ineffective airway clearance related to retained secretions as manifested by abnormal breath sounds particularly wheezes

Immediate Cause Asthma Intermediat e Cause Diffuse airway Inflammation Primary Cause Exposure to indoor and outdoor allergens Health Implication Increased amount and viscosity of secretions and /or inability to clear secretions through the

Goal: After an 8hour shift, the clients secretions would be lessened. Objectives: 1. After 30 minutes, the client will be able to expel mucous by: a. Doing proper coughing technique

Effectivenes s (1) Was the client able to expel mucus? __yes __no __why? - The client was able to expel mucus with the help of proper nursing interventions (Proper coughing technique, proper deep breathing exercises, chest percussion, Positioning and administratio n of drugs as ordered)

Developmen tal a. Teach the client and the relatives about proper coughing technique

b. Doing proper deep breathing exercises

b. Teach the client about proper deep breathing exercises

The patient needs to cough to be able to remove the mucus (p530, Smeltzer, MedicalSurgical Nursing Vol 1) Deep breathing exercises

verbalized, Nag start yung asthma niya nung 40 years old siya Observation - Nasal flaring - Breathing with effort as evidenced by use of accessory muscles - Difficulty of breathing - Difficulty in vocalizing Restlesssness - Ineffective cough - wheezing sound upon auscultation Measureme nt Respiratory rate: 28 cpm Pulse Rate: 94 bpm

normal cough mechanism may lead to pooling of secretions in lower airways. Pooling of secretions leads to infection and inadequate gas exchange. (p.229, Nettina, Manual of nursing practice) (Fundamental s of Nursing by Craven and Hirnle, 4th edition page 813)

c. Applying chest percussion

permits proper lung expansion and to be able to remove the mucus Supplement secretions al (p872, c. Apply chest Smeltzer, percussion to Medicalthe client Surgical Nursing Vol 1) Chest physiotherap y is important in loosening and mobilizing secretions. Indications for chest physiotherap y include sputum retention not responsive to spontaneous or directed cough,

(2) Was the client able to maintain adequate hydration? __yes __no __why? - The client was able to maintain adequate hydration due to the increase fluid intake as an intervention (3) Was the client able to be monitor regarding to his respiratory functioning? __yes __no __why? - The client was monitored regarding her respiratory

Oxygen Therapy: 6 L/min IV Fluid: PLR 1L 15 gtts/min x 16 hours

d. chest drainage

Supplement al d. position the client for postural drainage

e. administratio n of drugs

Facilitative e. Administer antibiotics as ordered

abnormal chest x-ray findings consistent with infiltrates or deterioration in oxygenation. (p520, Smeltzer, MedicalSurgical Nursing vol 1)

functioning every 2 hours

Efficiency Was the interventions done within the time frame? __yes __no __why? - The interventions done within the 8 hour shift Appropriate ness Were the interventions suitable to the client's situation? __yes __no __why? - The interventions

2. The client will be able to maintain adequate hydration by: Supplement al a. Increase a a. Increasing number of oral fluid fluids being intake drunk by the patient.

The patient is placed in the proper position to drain the involved lung segments. (p530, Smeltzer, MedicalSurgical Nursing vol 1) For infection (p412,

NANDA)

done was suitable to the clients situtation

b. regulating intravenous fluid

Supplement al b. Regulate the IV fluid as ordered

Adequacy Were the interventions adequate to An increased meet the respiratory client's rate leads to needs? an increase in __yes __no insensible __why? fluid loss during The clients exhalation need was and can lead met. to dehydration. Acceptabilit (p530, y Smeltzer, Were the Medicalinterventions Surgical vol acceptable to 1) the client? __yes __no __why? Administratio n of this fluid - The client generally accepted the causes interventions dilution of done

Supplement al 3. Respiratory a. Auscultate Monitoring breath sounds and assess air movement

b. Monitor rate, rhythym, depth, and effort of respirations

plasma solute concentration and forces water movement into cells to re-establish intracellular and extracellular equilibrium; cells then expand or swell. (p84, Nettina, Manual of nursing practice)

To Assert status and note progress (Nurse's Pocket Guide by Doenges, Moorhouse

and GeisslerMurr, 9th edition, page 71) Abnormality indicates respiratory compromise. Provide basis for evaluating adequacy of ventilation (Fundamental s of Nursinf by kozier, 7th edition page 1327)