Ampicillin Care Plan ATI Template

CARE PLAN Assessment ALLERGIES: • Ampicillin CODE STATUS: • Full Code PRECAUTIONS: • Fall Precautions Restraints: • N/A CC: Pneumonia and exacerbation of COPD DX: • Pneumonia • Exacerbation of COPD Past Surgeries/ Medical History: • Chest tube • Pneumonia • COPD • Pleural effusion NANDA Nursing DX 1. Ineffective airway clearance r/t increased production of secretions AEB abnormal breath sounds. Plan/ Goal Interventions Evaluation 1. Pt will demonstrate behaviors to improve airway clearance by the end of clinical shift AEB coughing effectively and expectorating secretions 1. Auscultate breath sounds every 1 to 4 hours. Breath sounds are normally clear or scattered fine crackles at bases, which clear with deep breathing period the presence of coarse crackles during late inspiration indicates fluid in the airway; Wheezing indicates an airway obstruction (Ackley, 2017). 1. Goal met AEB pt coughed up secretions. 1-2. Monitor respiratory patterns including rate, depth, and effort. A normal respiratory rate for an adult without dyspnea is 12 to 16 breaths per minute. With secretions in the airway, the respiratory rate will increase (Ackley, 2017). 1-3. Monitor blood gas values and pulse oxygen saturation levels as available. An oxygen saturation of less than 90% or a partial pressure of oxygen of less than 80 mm Hg indicates Subjective Data: Pt is short of breath. Objective Data: 68-year-old male. Pt was awake and alert and oriented to time, place, and person. Pt has an IV that is saline locked in the left wrist. Scalp with even hair distribution with some thinning. Head is round and symmetrical. PERRLA. Nose even with no deviated septum. Ears symmetrical with no hearing devices. Mouth is normal resting and smiling. Lips are pink and dry. Neck and shoulders are symmetrical. Respiration rate not regular and labored. Lung sounds diminished significant oxygenation problems (Ackley, 2017). 1-4. Administer oxygen as ordered. Oxygen administration has been shown to correct hypoxemia (Ackley, 2017). 1-5. Position the client to optimize respiration. In a mechanically ventilated client, there is a decreased incidence of ventilator-associated pneumonia if the client is positioned at a 30-45 degree semi recumbent position rather than a supine position (Ackley, 2017). 2. Impaired gas exchange r/t altered oxygen supply AEB abnormal breathing. 2. Pt will demonstrate improved ventilation and adequate oxygenation of tissues by ABGs within patient’s normal range and be free of symptoms of respiratory distress. 2-1. Assess and record respiratory rate, depth. Note the use of accessory muscles, pursed-lip breathing, inability to speak or converse. Useful in evaluating the degree of respiratory distress or chronicity of the disease process (Ackley, 2017). 2. Goal met AEB ABG values in normal range and pt was free of respiratory distress. at base and has occasional rhonchi, wheezes in anterior and posterior upper lobes. The patient has S1S2 regular rate and rhythm. No gallops, rubs, or friction. Pulse present and strong. Bowel sounds present and normoactive in RUQ, RLQ, LUQ, LLQ. Abdomen is round and soft. Pt has a chest tube inserted. Skin appears to be intact, warm, and dry. Capillary refill on fingers and toes present within 2 seconds. The pt has a productive cough with yellow-green tenacious sputum. Vital Signs: Admission: BP: 150/40 P: 100 2-2. Assess and routinely monitor skin and mucous membrane color. Cyanosis may be peripheral (noted in nail beds) or central (noted around lips/or earlobes). Duskiness and central cyanosis indicate advanced hypoxemia (Ackley, 2017). 2-3. Monitor changes in the level of consciousness and mental status. Restlessness, agitation, and anxiety are common manifestations of hypoxia. Worsening ABGs accompanied by confusion/ somnolence are indicative of cerebral dysfunction due to hypoxemia (Ackley, 2017). 2-4. Monitor vital signs and cardiac rhythm. Tachycardia, dysrhythmias, and changes in BP can reflect the effect of systemic hypoxemia on cardiac function (Ackley, 2017). 2-5. Auscultate breath sounds, noting areas of decreased airflow and adventitious sounds. Breath sounds may be faint because of decreased airflow or areas of consolidation. Presence of wheezes may indicate bronchospasm or retained secretions. Scattered moist crackles may indicate interstitial fluid or cardiac decompensation (Ackley, 2017). R: 36 T: 99.2 O2: 91% 5L/NC Pain: 0/10 Hospital Meds: • Albuterol • Ceftriaxone • Acetaminophen Diagnostic Studies: • ABG • Chest X-Ray • CBC • Chem Profile • Metabolic Profile • UA • C&S of Sputum 3. Pt will perform better 3. Activity intolerance r/t breathing patterns by the imbalanced end of clinical shift AEB between pt performing prescribed oxygen supply physical therapy. and demand due to inefficient work of breathing AEB shortness of breath. 3-1. Assess the patient’s respiratory response to activity which includes monitoring of respiratory rate and depth, oxygen saturation, and use of accessory muscles for respiration. Patients with COPD can experience hypoxia during an increased activity and may need oxygenation to avoid hypoxemia which put them at risk for exacerbations of the condition (Ackley, 2017). 3-2. Maintain prescribed activity levels. Helps in building tolerance and minimizing episodes of dyspnea (Ackley, 2017). 3. Goal met AEB pt maintained normal breathing patterns. 3-3. Provide at least 90 minutes of undisturbed rest in between activities. Allotment of undisturbed rest reduces demand for oxygen and allows adequate physiologic recovery (Ackley, 2017). 3-4. Teach and assist the patient with active ROM exercises. Aids in building stamina and avoid complications of limited mobility (Ackley, 2017). 3-5. If needed, assist the patient for a referral to a pulmonary rehabilitation program. This program allows the patient to learn about nutrition, breathing and relaxation techniques, medication education, avoiding exacerbations, and ways on how to live better while having COPD (Ackley, 2017).