University:
West Coast University
Course:
NURS 110 | Introduction to Professional Nursing
Academic year:

2021
Views:

330

Pages:

2
Author:

Charlee Buchanan

CARE PLAN Course: Student Name: Date: Score: Nursing Problem: inability to clear secretions or obstructions from respiratory tract Nursing Diagnosis (NANDA statement): ineffective airway clearance Related to (risk factors and etiologies): excessive mucus, retained secretions, impaired swallowing, aspiration As evidenced by (s/sx, diagnostic test results): dyspnea, ineffective coughing, difÏculty verbalizing, O2 saturation level below 95% Three short term goals:(Please use S.M.A.R.T. goals (specific, measurable, applicable, realistic and time-referenced) • STG – Patient will demonstrate effective coughing and other behaviors to achieve airway clearance by 3rd day of admission. One long term goal:  LTG – Patient will maintain patent airway by effectively clearing secretions at all times until discharged home. Five Interventions: Rationales/Reason for doing Interventions: Person Responsible: RN, LVN, MD • Auscultate breath sounds every 1-4 • In severe exacerbation of chronic hours for crackles and wheezes. obstructive pulmonary disease (COPD), lung sounds may be • Position the patient in a diminished or distant with air semirecumbent position w/HOB at tapping. 30-45 degree angle to decrease the aspiration of gastric oral and nasal • Doing so will lower the diaphragm secretions. and promote chest expansion, mobilization, and expectoration of • Encourage the client to use an secretions. incentive spirometer. If the client cannot be ambulated, turn the • Body movements and use of the patient side to side at least every 2 incentive spirometer helps mobilize hours. secretions. • Help the patient deep breathe and perform controlled coughing. • Administer oxygen as ordered. • Controlled coughing uses the diaphragmatic muscles, making the coughing more forceful and effective. • Oxygen administration haas been shown to correct hypoxemia. Administer humidified oxygen through an appropriate device. Outcome/Goals Evaluation: (Are the goals met, not met or progressing? If not met, what will you change in order for the patient to meet the goals? What data were used to evaluate if goals were met?) STG – Patient goal achieved. Patient correctly demonstrated effective coughing and other behaviors to achieve airway clearance. LTG – Patient goal partially achieved. Patient maintained patent airway 50% of the time. Will continue to monitor and evaluate until discharge.