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After 6 hours of nursing intervention, the cliet will be able to cough effectively and clear own secretions. After 5 days of intervention, the client maintained patency of airway and had clear breath sounds.
Deskripsi Asli:
Judul Asli
nursing care plan for upper resrpiratory tract infection
After 6 hours of nursing intervention, the cliet will be able to cough effectively and clear own secretions. After 5 days of intervention, the client maintained patency of airway and had clear breath sounds.
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After 6 hours of nursing intervention, the cliet will be able to cough effectively and clear own secretions. After 5 days of intervention, the client maintained patency of airway and had clear breath sounds.
Hak Cipta:
Attribution Non-Commercial (BY-NC)
Format Tersedia
Unduh sebagai DOC, PDF, TXT atau baca online dari Scribd
Subjective: Ineffective Airway STG: 1. Monitor VS 1. to assess baseline STG:
“nahihirapan ako Clearance related to After 6 hours of every 2 hrs. data. After 6 hours of huminga dahil sa thick tenacious nursing 2. encourage patient 2.promotes maximal nursing ubo ko”, as secretions and intervention, the to position in high- lung function. intervention, the verbalized by the airway obstruction cliet will be able to Fowler’s or semi- cliet had been able patient. as manifested by cough effectively Fowler’s positon. to cough effectively shallow respiration, and clear own 3. turn patient every 3.repositioning and clear own Objective: tachypnea and fever. secretions. 2 hrs and prn. promotes drainage secretions. >inability to cough of pulmonary Goal was met. effectively LTG: secretions and >shallow After 5 days of enhances ventilation LTG: respirations nursing to decrease potential After 5 days of >febrile intervention, the of atelectasis. nursing >anxiety client will maintain 4.teach client to 4.to help thin intervention, the >restlessness patency of airway maintain adequate secretions. client maintained >adventitious breath and will have clear hydration by patency of airway sounds breath sounds. drinking at least 8- and had clear breath >tachypnea 10 glasses of sounds. >use of accessory fluid/day ( if not Goal was met. muscle while contraindicated). breathing 5. teach and 5.to conserve supervise effective energy and to coughing reduce airway techniques. collapse. .6. perform Chest 6.CPT techniques Physical therapy. utilizes forces of gravity and motion to facilitate secretion removal. 7. instruct on 7.promotes splinting abdomen increased expiratory with pillow during pressure. coughing efforts. . 8..monitor airway 8.requires if patient for patency and cannot maintain provide artificial airway patency. airways as warranted. 9. administer 9. to improve bronchodilators as ventilation and ordered. maximizes air exchange. 10. instruct 10. may indicate client/family to bronchial tubes are notify nurse if the blocked with client is mucus, leading to experiencing hypoxia and shortness of breath hypoxemia. or air hunger. 11. instruct 11. promotes client/family prompt regarding identification of medications, effects, potential adverse side effects and reaction to facilitate symptoms of timely intervention. adverse effects to report to nurse or physician.