Nursing Care Plan Diagnosis

Assessment (Supporting data) Nursing Diagnosis (NANDA diagnostic statement) Subjective: Pt presented at ED with C/O SOB and dypsnea Ineffective airway clearance r/t secretions in bronchi and obstructed airway aeb hypoxemia and dypsnea Goals & Expected Outcomes (Realistic, timed, measurable)  Pt will maintain a patent airway at all times  Pt will demonstrate improved ventilation and adequate oxygenation within normal parameters for her as evidenced by blood gas levels before d/c Objective: Pt was hypoxemic at admission; spoke in short sentences; used acc. muscles when breathing   Pt will maintain clear lung fields and remain free of signs of respiratory distress throughout hospital stay Pt will Demonstrate effective coughing techniques after teaching session Nursing Interventions (Strategies or actions for care) Rationale for interventions  Monitor resp. rate, depth, and effort, use of accessory muscles, nasal flaring, and abnml breathing patterns. ↑ respiratory rate, use of accessory muscles, nasal flaring, and abdominal breathing may indicate hypoxia.  Auscultate breath sounds Q1- 2 °. Presence of crackles, wheezes may signify airway obstruction, leading to or exacerbating existing hypoxia.  Observe sputum, noting color, odor, and volume. Normal sputum is clear or gray and minimal; abnormal sputum is green, yellow, or bloody; malodorous; and often copious.  Monitor pt’s behavior and mental status for onset of restlessness, agitation, confusion, and (in the late 1 Evaluation (Client’s response to nursing actions & progress toward achieving goals & outcomes) Pt’s airway remained open Pt’s lungs remained free of new onset wheezes Pt demo’d effective coughing techniques for student nurse stages) extreme lethargy. Changes in behavior and mental status can be early signs of impaired gas exchange  Monitor oxygen sats continuously with pulse ox. Note blood gas results as available. An oxygen saturation of less than 90% or a partial pressure of oxygen of less than 80 mm Hg (normal: 80 to 100 mm Hg) indicates significant oxygenation problems  Observe for cyanosis of the skin; especially note color of the tongue and oral mucous membranes.  If acutely dyspneic, consider having pt lean forward over a bedside table, if tolerated. Leaning forward can help decrease dyspnea, possibly because gastric pressure allows better contraction of the diaphragm).  Help pt deep breathe and 2 perform controlled coughing. Have pt inhale deeply, hold the breath for several seconds, and cough two or three times with the mouth open while tightening the upper abdominal muscles as tolerated. This technique can help increase sputum clearance and decrease cough spasms. Teach pt to use the forced expiratory technique, the "huff cough." This technique prevents the glottis from closing during the cough and is effective in clearing secretions in the central airways  Administer humidified oxygen through an appropriate device (per the physician's order); watch for onset of hypoventilation aeb ↑somnolence after initiating or increasing O2 tx. Pts with chronic lung disease may need a hypoxic drive to breathe and may hypoventilate during O2 tx 3  Encourage increased fluid intake of up to 2500 ml/day within cardiac or renal reserve. Fluids help minimize mucosal drying and maximize ciliary action to move secretions Assessment (Supporting data) 4 Nursing Diagnosis (NANDA diagnostic statement) Goals & Expected Outcomes (Realistic, timed, measurable) Nursing Interventions (Strategies or actions for care) Rationale for interventions Evaluation (Client’s response to nursing actions & progress toward achieving goals & outcomes)  Subjective: Impaired Swallowing r/t esophageal defects aeb abnormality in esophageal phase by swallow study  Objective: Barium esphogram found evidence of presbiesophagus and silent penetration to vocal chords  Pt will demonstrate effective swallowing without choking or coughing during meals on this student’s shift Pt will remain free from aspiration aeb clear lungs clear, temp WNL during hospital stay Pt will return demonstrate understanding of appropriate swallowing techniques after teaching session  Determine the client's readiness to eat. The client needs to be alert, able to follow instructions, able to hold the head erect, and able to move the tongue in the mouth.  Watch for uncoordinated chewing or swallowing; coughing immediately after eating or delayed coughing, which may indicate silent aspiration; pocketing of food; wetsounding voice; sneezing when eating; delay of more than 1 second in swallowing; or a change in respiratory patterns. If any of these signs is present, put on gloves, remove all food from the oral cavity, stop feedings, and consult with a speech and language pathologist and a dysphagia team if available. These are signs of impaired swallowing and possible aspiration  Avoid providing liquids until the client is able to swallow effectively. Add a 5  Pt did not choke or cough during meals  Pt temp remained WNL during hospital stay  Pt was able to demo. appropriate swallowing techniques after teaching session; may need reinforcing before d/c thickening agent to liquids to obtain a soft consistency that is similar to nectar, honey, or pudding, depending on the degree of swallowing problems. Liquids can be easily aspirated; thickened liquids form a cohesive bolus that the client can swallow with increased efficiency  Have suction equipment available during feeding.  Watch for signs of aspiration and pneumonia. Auscultate lung sounds after feeding. Note new crackles or wheezing, and note elevated temperature. Notify the physician as needed. The presence of new crackles or wheezing, an elevated temperature or white blood cell count, and a change in sputum could indicate aspiration of food . It could also indicate the presence of pneumonia. Clients with dysphagia are at serious 6 risk for aspiration pneumonia  Watch for signs of malnutrition and dehydration. Keep a record of food intake. Malnutrition is common in dysphagic clients. A food intake record will allow the nurse, speech and language pathologist, and dietitian to determine the adequacy of nutritional intake. Assessment (Supporting data) 7 Nursing Diagnosis (NANDA diagnostic statement) Goals & Expected Outcomes (Realistic, timed, measurable) Nursing Interventions (Strategies or actions for care) Rationale for interventions Evaluation (Client’s response to nursing actions & progress toward achieving goals & outcomes) Subjective:  c/o increased cough, increased sputum Infection r/t chronic respiratory disease process aeb chest congestion, increased neutophil count  Objective: Wbc increased, neutrophils high Pt will have no futher s/sx of respiratory infection after antibiotic tx aeb wbc wnl, afebrile temps, and nonmucopurulent sputum Pt will verbalize understanding of measures to prevent infection such as adequate nutrition, activity, and immunizations  Monitor for signs of infection  Administer abx as ordered  Encourage increased fluid intake of up to 2500 ml/day within cardiac or renal reserve. Fluids help minimize mucosal drying and maximize ciliary action to move secretions  Increase pt’s level of activity as tolerated. Helps to improve oxygenation and decrease secretion retention  Teach pt and family s/sx of infection, and when to report to doctor 8 Pt showed no further s/sx of infection during stay in hospital