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    Nursing Care Plan Sheet Sample

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    dbryant0101
    The nursing care plan addresses a patient with an ineffective airway clearance diagnosis. The plan includes cough enhancement to promote deep breathing and forceful coughing to clear secretions. Objectives include improving respiratory status and airway patency. References are provided on respiratory conditions and nursing intervention classifications.

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    Nursing Care Plan Sheet Sample

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    dbryant0101
    8K views3 pages
    The nursing care plan addresses a patient with an ineffective airway clearance diagnosis. The plan includes cough enhancement to promote deep breathing and forceful coughing to clear secretions. Objectives include improving respiratory status and airway patency. References are provided on respiratory conditions and nursing intervention classifications.

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    The nursing care plan addresses a patient with an ineffective airway clearance diagnosis. The plan includes cough enhancement to promote deep breathing and forceful coughing to clear secretions. Objectives include improving respiratory status and airway patency. References are provided on respiratory conditions and nursing intervention classifications.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF or read online from Scribd
    Download as pdf
    8K views3 pages

    Nursing Care Plan Sheet Sample

    Uploaded by

    dbryant0101
    The nursing care plan addresses a patient with an ineffective airway clearance diagnosis. The plan includes cough enhancement to promote deep breathing and forceful coughing to clear secretions. Objectives include improving respiratory status and airway patency. References are provided on respiratory conditions and nursing intervention classifications.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF or read online from Scribd
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    Nursing Care Plan Sheet - Sample

    Date: 11/08/2004
    Student Name: Jane Doe
    Instructor: Jim Smith
    Patient Initials: J.D.3
    Medical
    Diagnosis:

    Assessment NANDA
    Nursing Diagnosis (copy and paste INEFFECTIVE AIRWAY CLEARANCE (1980, 1996,
    from NNN Linkages or, see NANDA): 1998)

    Definition of diagnosis (copy and paste


    from NNN Linkages Glossary or, see Definition
    NANDA): Inability to clear secretions or obstructions from the respiratory
    tract to maintain a clear airway

    Defining Characteristics
    *Dyspnea; *diminished breath sounds; *orthopnea; adventitious
    breath sounds (rales, crackles, rhonchi, wheezes) ; cough,
    ineffective or absent; *sputum; *cyanosis; *difficulty vocalizing;
    *wide-eyed; *changes in respiratory rate and rhythm;
    *restlessness

    Related Factors
    Environmental: *Smoking; *smoke inhalation; *second-hand
    smoke
    Obstructed airway: *airway spasm; *retained secretions;
    *excessive mucus; *presence of artificial airway; *foreign body in
    airway; *secretions in the bronchi; *exudate in the alveoli
    Physiological: *Neuromuscular dysfunction; (hyperplasia of the
    bronchial walls; *chronic obstructive pulmonary disease;
    *infection; *asthma; *allergic airways

    Note:
    Definition modified in the 1998 DRC revision process; *marks
    revised defining characteristics and related factors. This
    diagnosis was revised by NDEC.

    Subjective Data Objective Data

    Page 1
    Planning NOC
    Goals: Same as attached indicators and success scale levels
    Definitions for each outcome Respiratory Status: Airway Patency -----
    (copy and paste from NNN Linkages Extent to which the tracheobronchial passages
    or, see NOC): remain open

    Nursing Activities NIC


    Nursing Intervention Group (checkmark) (see chart below):
    1. Physiological: Basic (Classes A-F) 4. Safety (Classes U-V)
    x 2. Physiological: Complex (Classes G-N) 5. Family (Classes W, X, Z)
    3. Behavioral (Classes O-T) 6. Health System (Classes Ya-Yb)
    7. Community (Classes Yc-Yd)
    Definitions for each intervention Cough Enhancement -----
    (copy and paste from NNN Linkages Promotion of deep inhalation by the patient with
    or, see NIC): subsequent generation of high intrathoracic pressures
    and compression of underlying lung parenchyma for
    the forceful expulsion of air

    References (APA style)


    American Heart Association. (2004). Air patency statistics. Retrieved October 5, 2004, from
    http://www.americanheart.org/presenter.jhtml?identifier=536
    Dochterman, J.M., & Bulechek, G.M. (Eds.). (2004). Nursing interventions classification (NIC) (4th ed.).
    St. Louis: Mosby, an affiliate of Elsevier.
    Johnson, M., Bulechek, G. Dochterman, J.M., Maas, M., & Moorhead, S. (Eds.). (2001). Nursing
    diagnoses, outcomes, and interventions: NANDA, NOC, and NIC linkages. St. Louis: Mosby, an
    affiliate of Elsevier Science.
    Johnson, M., Bulechek, G., Dochterman, J.M., Maas, M., & Moorhead, S. (2003). Nursing diagnoses,
    outcomes, and interventions: NANDA, NOC, and NIC linkages [computer software]. New York:
    Mosby, a division of Elsevier Science.
    Kozier, B. (2004). Fundamentals of nursing: Concepts, process, and practice. Upper Saddle River, NJ:
    Prentice Hall Health.
    Moorhead, S., Johnson, M., & Maas, M. (Eds.). (2004). Nursing outcomes classification (NOC) (3rd ed.).
    St. Louis: Mosby, an affiliate of Elsevier.
    Murdoch, M., Sheridan, S.A., Doeden, M.L., Wilt, T.J., & Rubins, H.B. (2000). Impact of a low-cost
    intervention to increase diagphragmatic breathing awareness among older patients. Journal of
    Clinical Outcomes Management, 7, 31-39.
    Woods, A. (2002). Respiratory status and airway patency. Nursing, 32(6), 56-57. Retrieved October 5,
    2004, from CINAHL.

    Page 2
    NIC Groups

    1 Physiological: 2 Physiological: 3 Behavioral 4 Safety 5 Family 6 Health 7 Community


    Basic. Complex System
    A Activity & G Electrolyte & O Behavior U Crisis W Childbearing Y Health Yc Community
    Exercise Mgt. Acid-Base Mgt. Therapy Mgt Care System Health
    Mediation Promotion
    B Elimination H Drug Mgt P Cognitive V Risk Z Childrearing Ya Health Yd Community
    Mgt Therapy Mgt Care System Risk Mgt
    Mgt
    C Immobility Mgt I Neurological Mgt Q Communication X Lifespan Yb Information
    Enhancement Care Mgt
    D Nutrition J Perioperative R Coping
    Support Care Assistance
    E Physical K Respiratory Mgt S Patient Ed.
    Comfort
    Promotion
    F Self-Care L Skin/Wound Mgt T Psychological
    Facilitation Comfort
    Promotion
    M Thermoregulation
    N Tissue Perfusion
    Mgt

    Page 3

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