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Chapter IX NURSING CARE PLAN

DIAGNOSIS Ineffective Airway Clearance r/t retained bronchial secretions secondary to pneumonia as manifested by productive cough, increased respiration rate, tachypnea, use of accessory muscles in respiration, and crackles Cues: Objective: >Productive Cough >Respiration rate=30 cpm >Rapid shallow breaths >Use of accessory muscles in respiration

NEED

P H Y S I O L O G I C N E E D

DESIRED OUTCOME Within 8 hours of Nursing Interventions, the patient will be able to: General: >Enhance airway patency Specifically, >Demonstrate absence or reduction of congestion as evidenced by clearing secretions, normal respiration rate, normal breathing pattern, with clear breath sounds and noiseless respirations

INTERVENTIONS INDEPENDENT Establish rapport to the patient

RATIONALE

EVALUATION STATEMENT January 24, 2011 3:00 PM Goal is partially met.

INTERVENTIONS

RATIONALE For evaluation of effective airway clearance

Continue
Nursing Interventions especially monitoring respiration rate, depth, pattern, and breathing sounds

To gain clients trust and cooperation

Monitor vital
signs frequently especially respiration and interpret it accurately

To see
trends including progress of condition or any unusual signs and to evaluate patency of airway

Mr. C has
enhanced his airway patency since he was able to clear secretions by proper coughing. However, his respiration rate is 24 cpm, which is elevated from the normal range of 12-20 cpm, he still demonstrate d rapid shallow

provide
comfort measures, health teachings, and provide clean environment that is almost free from dust

To provide
comfort and prevent fatigue

For proper
understandin g towards complete treatment of the problem To maintain airway patency for patients comfort and relief

Monitor rate,
rhythm, depth, pattern, and sounds of breathing

To know the
effectiveness of the airway inside the body and provides a basis for future comparison To match the right intervention

Administer
expectorants as ordered/prescr ibed

Identify the causative factors

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>Crackles present upon auscultation >X-ray result showed evidence of pneumonia Do bedside care Monitor patients ability to cough effectively

against the specific causative agent To provide comfort

breathing, and crackles are still present

Respiratory
tract infections alter the amount of secretions. An ineffective cough compromises airway clearance and prevents mucus from being expelled

Background Knowledge: Upper airway characteristics normally prevent potentially infectious particles from reaching the sterile lower respiratory tract. Pneumonia arises from normal flora present in patients whose resistance has been altered. Patients often have an acute or chronic underlying disease that impairs host defenses. Pneumonia may also result from bloodborne organisms that enter the pulmonary circulation and are trapped in the

Provide with rest intervals with quiet environment and wellventilated area Position comfortably; elevate head or have the patient in an upright position Provide

To prevent
fatigue and reserve energy for other therapeutic activities To facilitate respiratory function by use of gravity

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pulmonary capillary bed. Pneumonia affects both ventilation and diffusion. An inflammatory reaction can occur in the alveoli, producing an exudate that interferes with the diffusion of oxygen and carbon dioxide. White blood cells, mostly neutrophils, also migrate in the alveoli and fill the normally aircontaining spaces. Areas of the lung are not adequately ventilated because of secretions that cause partial occlusion of the bronchi or alveoli, with a resultant decrease in alveolar oxygen tension. Mr. C has productive cough with an increased respiration rate. He uses accessory muscles to assist him during

supplemental humidification like nebulization and supplying direct oxygen

To reduce
difficulty of breathing by opening the airways and increase lung tissue oxygen supply

Render health
teachings which may be helpful after discharge such as keeping away environmental pollutants such a dust, smoke, and feather pillows from the patient Encourage significant others to provide warm versus cold liquids

These
precipitators of allergic type of respiratory reactions trigger onset of acute or chronic episodes of respiratory disorders

To avoid spasm of the bronchi

DEPENDENT

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breathing. His x-ray results also confirmed that he has pneumonia. Reference: Brunner, et al. Textbook of Medical-Surgical Nursing. Ed. 11. Vol 1. Lippincott Williams & Wilkins. Philadelphia. 2007 To increase the production of respiratory tract fluids to help liquefy and reduce the viscosity of secretions.

Administer
guaifenesin as prescribed

DIAGNOSIS Ineffective renal tissue perfusion r/t

NEED

DESIRED OUTCOME Within 2 days of Nursing

INTERVENTIONS INDEPENDENT

RATIONALE

EVALUATION STATEMENT January 26, 2011

INTERVENTIONS

RATIONALE To prevent complication

Continue
Nursing

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hypovolemia and diminished blood flow to the kidney as manifested by prolonged low blood pressure and decreased urine output Cues: Objective: >BP=50/20 mmHg >Muscle Weakness >Loss of Appetite >Nausea and vomiting >Increased Serum Creatinine=5.8mg/d L >Decreased Potassium=2.8 mmol/L >Decreased Sodium=130mmol/ L >Decreased Calcium=1.37mmol /L >Metabolic

H Y S I O L O G I C N E E D

Interventions, the patient will be able to: General: >Demonstrate increased renal perfusion Specifically, >have normal vital signs, absence of edema, normal potassium, sodium, calcium, and creatinine level

Establish rapport to the patient

To gain
clients trust and cooperation as well as have a quality assessment Hypotension particularly with correspondin g changes in pulse rate may reflect hypovolemia Oliguria is a sign of decreased perfusion; fluid balance indicates circulatory status and replacement needs Too much sodium will make the condition worse like complicating edema

3:00 PM Goal is partially met.

Mr. C
demonstrate d evidences of increased renal perfusion such as stable vital signs, normal serum creatinine level=1.5mg/ dL, and normal potassium level=4.1mm ol/L. However, latest result for sodium and calcium level is not available and there is still presence of 1+ edema on both feet

Interventions especially close monitoring and referring to physicians complications that may arise Administer physicians prescribed medicine

and further damage to kidneys

Monitor vital signs frequently especially respiration and interpret it accurately

For faster treatment hat will lead to recovery

Monitor intake and output; observe fluid and electrolyte and balance; assess signs of dehydration

Monitor clients diet to enforce mild to moderate sodium and fluid restriction especially if edema is severe

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Acidosis (pH=7.1; HCO3=5.3mmol/L) >Loose bowel movement >Presence of Edema >Decreased urinary output amounted to 400cc a day Background Knowledge: Hypovolemic shock can be caused by external fluid losses, as in severe internal fluid shifts, as in severe dehydration, edema. Intravascular volume can be reduced both by fluid loss and by fluid shifting between the intravascular and interstitial compartments. The sequence of events in hypovolemic shock

Maintain client on bed rest; elevate lower extremities

Activity
increases production of nitrogenous waste products; o mobilize edema since edematous tissues are more prone to breakdown; promotes venous return, limiting venous stasis, and edema formation

DEPENDENT Administer IV fluids as indicated

Fluid replacement depends on the degree of hypovolemia This allow the nurse to monitor the kidneys which have the major role in regulating fluid and

Insert
indwelling urinary catheter and measure output

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begins with a decrease in intravascular volume. This results in decreased venous return of blood to the heart and subsequent decreased ventricular filling. Decreased ventricular filling results in decreased stroke volume which is the amount of blood ejected from the heart and may decrease cardiac output. When cardiac output drops, blood pressure drops and tissues cannot be adequately perfused specifically in the organ involved in the case of Mr. C, the kidneys. Mr. C has acquired renal failure due to prolonged hypotension secondary to hypovolemic shock which is very

electrolyte balance Monitor clients blood count This establishes fluid status and need for fluid replacement

Monitor ABG values

Acidosis and
hypoxemia must be reported To assess renal function; increase BUN, creatinine, and other electrolytes indicate presence and degree of kidney dysfunction

Monitor BUN, creatinine, proteinuria, and serum electrolytes

Administer
prescribed medication sodium bicarbonate Agent used to alkalinize

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or maintain homeostasis Maintains bone health evident on the manifestations shown by the patient. calcium + vitamin D cefuroxime Effective against susceptible bacteria causing infections To increase rate of urination furosemide Prevent vomiting and effective against nausea To initially improve renal perfusion; resulting in an increase of urine flow RATIONALE EVALUATION STATEMENT January 26, 2011 3:00 PM Goal is partially met. INTERVENTIONS Continue Nursing Interventions especially close monitoring and RATIONALE

Reference: Brunner, et al. Textbook of Medical-Surgical Nursing. Ed. 11. Vol 1. Lippincott Williams & Wilkins. Philadelphia. 2007

metoclopramid e

dopamine

DIAGNOSIS Fluid Volume Deficit r/t active fluid loss as manifested by diaphoresis, emesis and loose bowel movement

NEED

P H Y S

DESIRED OUTCOME Within 2 days of Nursing Interventions, the patient will be able to: General:

INTERVENTIONS INDEPENDENT Establish rapport to the patient

To prevent
complication regarding fluid and electrolyte balance of

To gain clients trust and cooperation

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Cues: Objective: >Dry mouth >BP=50/20 mmHg >Muscle Weakness >Loss of Appetite >Nausea and vomiting >wt=55 kg >Increased Serum Creatinine=5.8mg/d L >Loose bowel movement >Presence of Edema >Decreased urinary output amounted to 400cc a day Background Knowledge: Acute renal failure causes severe nutritional imbalances. Almost

I O L O G I C N E E D

>Restore normal fluid volume Specifically, >show adequate urinary output of at least 1,400 mL a day, moist mucus membrane, stable vital signs, absence of vomiting, and loose bowel movement Monitor vital signs frequently especially respiration and interpret it accurately

as well as have a quality assessment

Hypotension
may be present; increased temperature may increase metabolism and exacerbate fluid loss Fluid replacement needs are based on correction of current deficits and ongoing losses; decreased urine output may indicate insufficient renal perfusion and hypovolemia Fluid deficit can result in inadequate organ perfusion to all areas and

Mr. C has restored normal fluid volume as shown by the following: Urinary output=900c c Mucous membranes are moistened BP=100/20 mmHg

referring to physicians complications that may arise Administer physicians prescribed medicine

the patient

For faster treatment hat will lead to recovery

Monitor intake
and output; observe fluid losses

(-) vomiting
Formed stools

Note capillary refill; skin color and temperature; palpate

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every system of the body is affected when there is failure of the normal renal regulatory mechanisms. The patient may appear critically ill and lethargic. The skin and mucous membranes are dry from dehydration. Maintenance of fluid balance is based on daily body weight, fluid losses, blood pressure, and the clinical status of the patient. Adequate blood flow to the kidneys may be restored by intravenous fluids or transfusion of blood products Reference: Brunner, et al. Textbook of Medical-Surgical Nursing. Ed. 11. Vol 2. Lippincott Williams & Wilkins. Philadelphia. 2007

peripheral pulses Monitor sudden or marked elevation of BP, restlessness, dyspnea, frothy sputum Evaluate patients ability to swallow Encourage small, frequent meals with foods high in protein and carbohydrates

may cause shock Too rapid correction of fluid deficit may compromise the cardiopulmo nary system It may affect patients ability to replace fluids orally To maximize nutrient intake without undue energy expenditure from eating large meals

Provide skin
and mouth care. Bathe every other day; apply lotion as indicated

Skin and
mucous membranes are dry with decreased elasticity; bathing daily increases dryness Decreased perfusion

Provide safety measures

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considering side rails, and frequent monitoring

may result in altered thought processes; protective measures will prevent the patient from injury

DEPENDENT

Administer oral
and IV fluids as indicated

Provides fluid replacement and assist nutritional needs of the patient To correct severe acidosis while correcting fluid balance

Administer sodium bicarbonate and other medicines prescribed

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