Nursing Care Table)

8/9/2019 Nursing Care Table)

1/35

Nursing care plan

Patient: Gladys Santos Age: 31 years old CC: cough

ASSESSMENT DIAGNOSIS RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:

kulang na dinako sa tulog kasi

masakit anglalamunan ko at

dibdib kapag

umuubo akokaya naiistorbo

ang tulog kotapos

nagpaconfine pa

ako. Nahihirapandin akong

huminga lalo nakapag nakahiga

ako, as

verbalized by thepatient

Objective:>cough

>Tachypnea.

RR of 38

P

Ineffective

airwayclearance

Related to

E copioustracheo-

bronchial

secretions

As

manifested

by

S

kulang nadin ako sa

tulog kasimasakit ang

lalamunan

ko at dibdib

Short term:

After 4-8 hoursof nursing

intervention, thepatient will be

able to:

>sustain arespiratory

rate between23-27

breaths per

minute

>express

ease on

breathing

>Allayrestless-ness.

Independent:

Assess airway forpatency.

Assess cough foreffectiveness and

productivity.

Assess patients

knowledge of

disease process.

Maintaining the

airway is always

the first priority,especially in

cases of trauma,

acuteneurologicaldecompensation,

or cardiac arrest.

Consider

possible causesfor ineffective

cough (e.g.,

respiratory

muscle fatigue,severebronchospasm, or

thick tenacioussecretions).

Patient education

will varydepending on the

Short term:

After 7 hours ofnursing

intervention, thepatient was able

to:

>sustained arespiratory

rate between23-27 breaths

per minute

>expressedease on

breathing

>

Allayedrestless-ness.

Goal met


2/35

>Patient prefers

high fowlers position so she

can breathebetter.>Dull thud at

upon percusiion.>Crackles are

present at rightand left lungs.

>Rhonchi are

heard over thelarge airways.

>Patient showsincreased

workload of

breathing.

kapag

umuubo akokaya

naiistorboang tulog kotapos

nagpaconfine pa ako.

Nahihirapandin akong

huminga

lalo nakapag

nakahigaako, as

verbalized

by thepatient,

cough,Tachypnea,

RR of 38,Patient

prefers high

fowlersposition,

Dull thud atupon

percusiion,

Cracklespresent at

right and

LONG TERM:

After 2-4 daysof nursing care,the patient will

be able to:> have

respirationrate between

18-25

breaths permin

>expectorate

secretionseffectively

> Normal

chest x-rayresults

>Allay restless-

ness>verbalized

improved

activitytolerance.

Assist patient in

performing

coughing andbreathing

maneuvers.Instruct patient in

the following:

>Optimal

positioning (sittingposition)

>Use of pillow orhand splints when

coughing

>Use of abdominal

muscles for moreforceful cough

>Use of quad and

acute or chronicdisease state as

well as the

patientscognitive level

These improveproductivity of

the cough.

Directed

coughingtechniques help

mobilize

secretions fromsmaller airways

to larger airwaysbecause the

coughing is doneat varying times.

The sitting

position andsplinting the

abdomen promote

more effectivecoughing byincreasing

abdominal

pressure andupward

diaphragmaticmovement.

LONG TERM:

After 3 days of

nursing care, thepatient was ableto:

> haverespiration

rate between18-25 breaths

per min

>expectorate

secretionseffectively

>have Normal

chest x-rayresults

>Allay restless-

ness>verbalized

improved activitytolerance.

Goal met


3/35

left lungs,

Rhonchi areheard over

the largeairways,Patient

showsincreased

workload ofbreathing

huff techniques

>Use of incentivespirometry

>Importance of

ambulation andfrequent position

changes

Use positioning (if

tolerated, head of

bed at 45 degrees;sitting in chair,ambulation).

Use humidity(humidified oxygen

or humidifier atbedside).

Encourage oral

intake of fluidswithin the limits ofcardiac reserve.

These promotebetter lung

expansion and

improved airexchange.

This loosens

secretions.

Increased fluid

intake reduces

the viscosity ofmucus producedby the goblet cells

in the airways. It

is easier for thepatient to

mobilize thinnersecretions with


4/35

pace activities.Maintain plannedrest periods.

Promote energy-conservation

techniques.

Demonstrate and

teach coughing,deep breathing, and

splintingtechniques.

Explain effects of

smoking, includingsecond-hand

smoke.

Dependent:

Administer

medications.Instruct patient on

indications for,

coughing.

Fatigue is a

contributingfactor to

ineffectivecoughing.

Patient will

understand therationale and

appropriate

techniques tokeep the airway

clear ofsecretions.

Smoking

contributes to

bronchospasmand increased

mucus production

in the airways.

To treat infection,

liquefy secretions

and let the patientbe aware of the

side effects.


5/35

frequency, and side

effects ofmedications.

Collaborative:

Consult respiratory

therapist for chestphysiotherapy and

nebulizertreatments as

indicated (hospital

and homecare/rehabilitation

environments).

Chest

physiotherapyincludes the

techniques ofpostural drainage

and chest

percussion tomobilize

secretions insmaller airways

that cannot be

removed bycoughing or

suctioning.


6/35

Nursing care plan

Patient: Gladys Santos Age: 31 years old CC: cough


Subjective:

wala naman

akong arthritis.Pakiramdam ko

ngayon ayparang lagi

akong

nanghihina kayamatamlay ako.

Kulang din akosa tulog., as

verbalized by the

patient.

Objective:

>Reluctance toattempt

movement>BP = 170/120

mmHg>RR = 38

breaths per

minute

P Activity

Intolerance

Related to

E impaired

respiratoryfunction,

anemia anddialysis

procedure

As

manifested

by

S

walanaman

akongarthritis.

Pakiramdam

ko ngayon

Short term:After 5-8 hours

of nursingintervention, the

patient will:>be willing to

participate in

activities relatedto her care

>identify

factors that can

help increaseher activity

tolerance

>plan a

schedule ofactivities to

preserve energyand utilize it

properly

>

Determine cause ofactivity intolerance

(see Related Factors)and determine

whether cause isphysical,

psychological, or

motivational.Determining thecause of a problem

can help direct

appropriateinterventions.

EditIf mainlyon bed rest,

minimize

cardiovasculardeconditioning by

positioning the clientin an upright position

several times daily ifpossible.

Deconditioning ofthe cardiovascular
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>Decreased

muscleendurance,

strength, control,or mass>body weakness

>tired facialexpression

ay parang

lagi akongnanghihina

kayamatamlayako. Kulang

din ako satulog., as

verbalizedby the

patient,

Reluctanceto attempt

movement,BP =

170/120

mmHg, RR= 38 breaths

per minute,Decreased

muscleendurance,

strength,

control, ormass, body

weakness,tired facial

expression

system occurswithindays and involves

fluid shifts, fluid

loss, decreasedcardiac output,

decreased peakoxygen uptake, and

increased resting

heart rate (Fletcher,2005;Fauci et al,

2008). A study foundthat diabetic clients

developed

orthostatichypotension after 48

hours of bed rest,possibly from altered

cardiovascularreflexes (Schneider

et al, 2009).

EditAssessthe client daily for

appropriateness of

activity and bed restorders. Mobilize theclient as soon as it is

possible. With bedrest there is a shift of

fluids from theextremities to the
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thoracic cavity fromthe loss of

gravitational stress.

Positioning in anupright position

helps maintainoptimal fluid

distribution and

maintain orthostatictolerance (Perme &

Chandrashekar,2009).EB: A study

utilizing tomography

demonstratedsignificant

decreased strengthin the hip, thigh, and

calf muscles inelderly orthopedic

clients, as well as

bone mineral losswith immobility

(Berg et al, 2007).

EditIf clientis mostly immobile,consider use of a

transfer chair: a chair

that becomes astretcher. Using atransfer chair where
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the client is pulledonto a flat surface

and then seated

upright in the chaircan help previously

immobile clients getout of bed (Nelson et

al, 2003;Perme &

Chandrashekar,2009).

EditWhenappropriate,

gradually increaseactivity, allowing the

client to assist with

positioning,transferring, and

self-care as possible.Progress from sitting

in bed to dangling, to

standing, toambulation. Always

have the client

dangle at the bedsidebefore tryingstanding to evaluate

for postural

hypotension.Posturalhypotension is very
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common in theelderly (Krecinic et

al, 2009).

EditWhengetting a client up,

observe forsymptoms of

intolerance such as

nausea, pallor,dizziness, visual

dimming, andimpaired

consciousness, aswell as changes in

vital signs. When anadult rises to the

standing position,300 to 800 mL of

blood pools in the

lower extremities. Asa result, symptoms of

central nervoussystem

hypoperfusion mayoccur, includingfeelings of weakness,

nausea, headache,lightheadedness,

dizziness, blurredvision, fatigue,
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tremulousness,palpitations, and

impaired cognition

(Bradley & Davis,2003).

EditIf theclient experiences

symptoms of

postural hypotensionas outlined above,

take precautionswhen getting the

client out of bed. Put

graduatedcompression

stockings on client oruse lower limb

compressionbandaging if ordered

to return blood to the

heart and brain. Havethe client dangle at

the side of the bed

with legs hangingover the edge of thebed, flex and extend

feet several times

after sitting up, thenstand up slowly with

someone holding the


12/35

client. If client

becomes lightheaded or dizzy,

return them to bedimmediately.Posturalhypotension is

common and can

occur with bothyounger and older

clients fromimmobility and

deconditioning. Use

of compressionstockings or leg

bandaging can helpreturn fluid from the

lower extremitiesback where it

collects from

immobility to theheart and brain

(Gorelik et al, 2009;

Platts et al, 2009). EditPerformrange-of-motion

(ROM) exercises if

the client is unable totolerate activity or is

mostly immobile.


13/35

See care plan for

Risk for Disuse

syndrome.

EditMonitorand record the

client's ability totolerate activity: note

pulse rate, blood

pressure, monitorpattern, dyspnea, use

of accessorymuscles, and skin

color before, during

and after the activity.If the following signs

and symptoms ofcardiac

decompensationdevelop, activity

should be stopped

immediately:

Onset of

chestdiscomfort

Dyspnea Palpitations

Excessivefatigue

Lightheadedn
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ess,

confusion,ataxia, pallor,

cyanosis,nausea, orany

peripheralcirculatory

insufficiency Dysrhythmia

Exercise

hypotension(drop in

systolic bloodpressure of

10 mm Hg

from baselineblood

pressuredespite an

increase inworkload)

Excessive

rise in bloodpressure

(systolic>180 mm Hg

or diastolic

>110 mmHg) Note:

These are


15/35

upper limits;

activity maybe stopped

beforereachingthese values

Inappropriatebradycardia

(drop in heartrate >10

beats/min or


16/35

or pressure in chest,

back, neck, jaw,shoulders, and/or

arms; palpitations;dizziness; weakness;unusual and extreme

fatigue; excessive airhunger. These are

common symptomsof angina and are

caused by atemporary

insufficiency of

coronary bloodsupply. Symptoms

typically last forminutes as opposed

to momentarytwinges. If symptoms

last longer than 5 to

10 minutes, theclient should be

evaluated by a

physician. Pulse rateand arterial bloodoxygenation indicate

cardiac/exercise

tolerance; pulseoximetry identifies

hypoxia (Grimes,2007; Schmitz,
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2007).

EditObserve

and document skin

integrity severaltimes a day. Activity

intolerance,if

resulting in

immobility, may leadto pressure ulcers.

Mechanicalpressure, moisture,

friction, and

shearing forces all

predispose to theirdevelopment (Fauciet al, 2008). Refer tothe care plan Risk

for impaired Skin

integrity.

EditAssessfor constipation. If

present, refer to care

plan forConstipation.

Activity intolerance

is associated with

increased risk ofconstipation.

EditRefer the
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client to physical

therapy to helpincrease activity

levels and strength.

EditConsider

a dietitian referral toassess nutritional

needs related to

activity intolerance,provide nutrition as

needed. If client isunable to eat food,

use enteral or

parenteral feedingsas needed.

EditRecognize that

malnutrition causessignificant morbidity

due to the loss oflean body mass.

Providing nutrition

early helps maintainmuscle and immunesystem function, and

reduce hospitallength of stay

(McClave et al,

2009;Racco, 2009).
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EditProvideemotional support

and encouragement

to the client togradually increase

activity. Work withthe client to set

mutual goals that

increase activitylevels.Fear ofbreathlessness, pain,

or falling may

decrease willingness

to increase activity.

EditObservefor pain before

activity. If possible,

treat pain beforeactivity and ensure

that the client is notheavily sedated.

Pain restricts the

client from achievinga maximal activitylevel and is often

exacerbated bymovement.

EditObtain

any necessary
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assistive devices or

equipment neededbefore ambulating

the client (e.g.,walkers, canes,crutches, portable

oxygen).Assistive

devices can help

increase mobility(Yeom, Keller, &

Fleury, 2009).

EditUse a

gait walking belt

when ambulating theclient. Gait beltsimprove the

caregiver's grasp,reducing the

incidence of injuries

(Nelson et al, 2003).

EditIf the

client is ableto walk and

has chronic

obstructivepulmonary

disease
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(COPD), usethe traditional

6minute walkdistance toevaluate

ability towalk.EB:The 6minutewalk test

predictedmortality in

COPD

clients(Pinto-Plata

et al, 2004).

EditEnsu

re that the

chronicpulmonary

client hasoxygen

saturation

testing withexercise. Use

supplementaloxygen to

keep oxygensaturation 90

or above or


22/35

as prescribed

with activity.Clients with

COPD maysuffer from

inadequategas

exchange.

Oxygentherapy can

improveexercise

ability and

ability tothink in

hypoxemicclients (Celli,

MacNee, &ATS/ERS

Task Force,

2004).

EditMoni

tor a

respiratoryclient'sresponse to

activity by

observing forsymptoms of

respiratory
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intolerance

such asincreased

dyspnea, lossof ability tocontrol

breathingrhythmically,

use ofaccessory

muscles,

nasal flaring,appearance of

facialdistress, and

skin tone

changes suchas pallor and

cyanosis(Perme &

Chandrashekar, 2009).

EditInstr

uct and assista COPDclient in

using

conscious,controlled

breathing
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techniques

duringexercise,

includingpursed-lipbreathing,

andinspiratory

muscle use.

EBN:A

systematicreview found

pursed-lip

breathingeffective in

decreasingdyspnea

(Carrieri-Kohlman et

al, 2008).

EB: Asystematic

review found

thatinspiratorymuscle

training was

effective inincreasing

endurance ofthe client and
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decreasingdyspnea

(Langer et al,

2009). EditEval

uate theclient's

nutritional

status. Referto a dietitian

if needed.Use

nutritional

supplementsto increase

nutritionallevel if

needed.Improved

nutrition mayhelp increase

inspiratorymuscle

function anddecreasedyspnea.

EBN:Astudy found

that almosthalf of a


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group ofclients with

COPD were

malnourished, which can

lead to anexacerbation

of the disease

(Odencrants,Ehnfors, &

Ehrenbert,2008).

EditFor

the client inthe intensive

care unit,consider

mobilizingthe client in a

four-phase

method ifthere is

sufficient

knowledgeable staffavailable to

protect the

client fromharm.Evenintensive
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care unitclients

receiving

mechanicalventilation

can bemobilized

safely if a

multidisciplinary team is

present tosupport,

protect, and

monitor theclient for

intoleranceto activity

(Perme &Chandrashek

ar, 2009).

EditReferthe COPD

client to a

pulmonaryrehabilitationprogram.

EB: ACochrane

review foundthat
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pulmonaryrehabilitation

has been

shown torelieve

dyspnea andfatigue

(Lacasse et

al, 2006).Another

Cochranereview found

pulmonary

rehabilitationeffective to

decreasemortality and

rate ofreadmission

for the client

who wasrecently

dischargedafter

treatment foran

exacerbation

of COPD(Puhan et al,

2009).
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Documents

Nursing Care Table)