Jeacey Paraluman, Daisyree Dano Z: Interventions

CAPITOL UNIVERSITY
COLLEGE OF NURSING
Name of Student: Jeacey Paraluman , Daisyree Dano Date of Assignment:

Name of Patient: Z Ward: Bed No.
NURSING CARE PLAN

ASSESSMENT DATA NURSING DIAGNOSIS GOALS AND OBJECTIVES NURSING INTERVENTIONS EVALUATION
(Subjective & Objective Cues) (Problem and Etiology) AND RATIONALE
Interventions: Assess rate and depth of
respirations and chest movement. The patient is in respiratory
Auscultate lung fields, noting areas of distress due to an exacerbation of
Subjective cues: Ineffective Airway decreased or absent airflow and chronic obstructive pulmonary
- Increased shortness of breath Clearance The patient should focus on improving adventitious breath sounds, such as disease (COPD) and possible
- Wheezing May Be Related To airway clearance, enhancing respiratory crackles and wheezes. infection. Subjective symptoms
- Productive cough with Infection [tracheal function, and reducing symptoms. The Monitor for signs of respiratory failure, include increased shortness of
greenish sputum bronchial inflammation, patient will demonstrate effective coughing for example, cyanosis and severe breath, wheezing, a productive
- Fatigue edema formation]; and clear secretions, with education on tachypnea. cough with greenish sputum,
- Unable to complete daily underlying chronic breathing techniques. Monitoring will Elevate head of bed; change position fatigue, and difficulty with daily
activities due to respiratory obstructive pulmonary ensure a normal respiratory rate and frequently. activities. Objective findings
distress disease Exudate in alveoli improvement in breath sounds within 48 Assist client with frequent deep-breathing reveal tachycardia (HR 100 bpm),
hours. Positioning strategies will aid lung exercises. Demonstrate and help client, as tachypnea (RR 24 cpm), and
Objective cues: Possibly Evidenced By expansion, and prescribed bronchodilators needed; learn to perform activity, such as hypoxemia (SpO2 88% on room
- Vital signs Changes in respiratory and expectorants will be administered to splinting chest and effective coughing air). The diagnosis of "Ineffective
- BP- 130/85 rate promote airway clearance, ultimately while in upright position. Airway Clearance" is appropriate,
mmHg decreasing dyspnea and allowing the Perform treatments between meals and and interventions should focus on
Diminished/adventitious
- HR- 100bpm patient to engage in daily activities with limit fluids when appropriate. improving airway clearance and
breath sounds Dyspnea,
- RR- 24cpm minimal distress. Suction, only as needed, for example, respiratory function through
cyanosis Ineffective cough
- Temp- 37 °F oxygen desaturation related to airway effective coughing techniques,
- SpO2 88% on room air secretions. deep breathing exercises, and
Etiology: These include
pneumonia, contact with certain Force fluids to at least 2500 mL per day, positioning strategies.
toxins, medications, trauma to unless contraindi- cated, as in HF. Offer Collaborative care will include
the chest wall, and traveling to or warm, rather than cold, fluids. nebulizer treatments,
exercising at high elevations bronchodilators, expectorants,
Rationale: Assess rate and depth of and monitoring for respiratory
respirations and chest movement. failure. This comprehensive
Auscultate lung fields, noting areas of approach aims to enhance lung
decreased or absent airflow and function and enable the patient to
adventitious breath sounds, such as resume daily activities with less
crackles and wheezes. distress.
Monitor for signs of respiratory failure,
for example, cyanosis and severe
tachypnea.
Elevate head of bed; change position
frequently.
Assist client with frequent deep-breathing
exercises. Demonstrate and help client, as
needed; learn to perform activity, such as
splinting chest and effective coughing
while in upright position.
Perform treatments between meals and
limit fluids when appropriate.
Suction, only as needed, for example,
oxygen desaturation related to airway
secretions.
Force fluids to at least 2500 mL per day,
unless contraindi- cated, as in HF. Offer
warm, rather than cold, fluids.
Collaborative
Assist with and monitor effects of
nebulizer treatments and other respiratory
physiotherapy, such as incentive
spirometer, intermittent positive-pressure
breathing (IPPB), percussion, and postural
drainage.
Administer medications, as indicated, for
example, expectorants, bronchodilators,
and analgesics.
Provide supplemental fluids such as IV,
humidified oxygen, and room
humidification.
Monitor serial chest x-rays, ABGs, and
pulse oximetry readings. (Refer to ND:
impaired Gas Exchange, following.)

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CAPITOL UNIVERSITY

Name of Student: Jeacey Paraluman , Daisyree Dano Date of Assignment:

NURSING CARE PLAN

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