University:
California State University, East Bay
Course:
NURS 3406 | Care of Clients with Psychiatric/Mental Health Needs
Academic year:

2020
Views:

316

Pages:

2
Author:

zbrkanogiorr

Nursing diagnosis objective/goals Interventions Rationale Evaluation Patient: Carlos Mancia Nanda DX: 1. Ineffective airway clearance r/t increased pulmonary secretions evidenced by blood tinged mucous secretions and productive cough 2. Impaired Verbal communica tion r/t language barrier as evidenced by noncomplia nce of mask and isolation precaution s Vital signs Temp 99.1, BP 124/62, P 77, RR 20, SaO2 91% Pertinent orders Rule out TB Pertinent assessment Neurological: WNL Short term: Patient will maintain clear, open airways as evidence by normal breath sounds, normal rate and depth of respirations, and ability to effectively cough up secretions after treatments and deep breaths. Patient shows clear understanding of instruction by following airborne precaution protocol and mask compliance Position the PT in semi Fowler when needed to promote comfort Administer meds as needed (ABX, …) Monitor PTs for change in respiratory status (SOB, O2 level) Provide resources written in spanish as well as translator available for the PT continuously Upright position limits abdominal contents from pushing upward and inhibiting lung expansion. This position promotes better lung expansion and improved air exchange. Medications are given to manage PT problems Any change in status should be addressed quickly to avoid further complications Ensuring a trusting relationship with the PT The Patient will show normal breathing sounds and no cough upon discharge from the hospital The patient will show understanding of tx and Diagnosis by using teach back method and verbal confirmation with the translator after every interaction Respiratory Pain level