NURSING CARE PLAN Nursing Diagnose Ineffecti e air!

a" c#earance re#ate$ to retaine$ secretion s CUES ANALYSIS GOALS AND OBJECTIV ES GOAL% After 3 )ours of nursing inter ention t)e -atient !i## 'e a'#e to ,aintain air!a" -atenc". OBJECTIV ES% After 4+ of nursing inter ention5 t)e -atient !i## 'e a'#e to $e,onstrat e effecti e 'reat)ing -attern. After 4+ ,inutes of nursing inter ention5 t)e -atient !i## 'e a'#e INTERVENTIO N COLLABORATI VE% Gi e 'ronc)o$i#ators suc) as Sa#'uta,o# /4 ,# 6*2 as -rescri'e '" t)e -)"sicians. INDEPENDENT % &,onitore$ ita# signs. &auscu#tate t)e #ungs. &CPT/c)est-)" sio t)era-)"2 &e#e ate t)e )ea$ of t)e -atient. To $i#ate t)e 'ronc)io#es5 to ,aintaine$ -atent air!a". RATIONALE EVALUATION

OBJECTI VE% &O'tain secretion s &Crac(#e s &Pro$ucti e coug) &Rest#es sness &RR% *+

Ina'i#it" to c#ear secretions or o'structions fro, t)e res-irator" tract to ,aintain a c#ear air!a". /)tt-%00nursingcri'.co,0nursing1care1 -#an0ineffecti e1air!a"1c#earance1rt1 secretions1in1t)e1'ronc)i0 2

After 8+ ,inutes of nursing inter ention t)e caregi er !i## 'e a'#e to er'a#i9e$ un$erstan$ing of t)era-eutic ,anage,ent.

&to ser e as 'ase#ine $ata. &to ser e 'ase#ine. &to #oosen secretion. &to ,aintaine$ o-en air!a".

7"$ration an$ #i6uif"

to $e,onstrat e i,-ro e,e nt of air!a".

SUPPLE:ENT AL% Encourage t)e caregi er to increase f#ui$ inta(e. DEVELOPE:E NTAL% Encourage t)e ,ot)er to $e,onstrate t)e inter ention $one. In$e-en$ent% AAssess -ain c)aracteristics/ 6ua#it"5 se erit"5#ocation 5 onset5$uration5 -reci-itating an$ re#ie ing factors2. AO'ser e or ,onitor signs an$ s",-to,s associate$ !it) -ain5suc) as BP5 )eartrate5 te,-erature5co# or an$ ,oisture of s(in5

secretion.

To (no! t)e contri'uting factors of t)e sai$ -ro'#e,.

Acute -ain re#ate$ to c)e,ica# 'urn of gastric ,ucosa

Su';ecti e% <Nasa(it una" titi"an (o5 #a#u nu(a#(a#as (o,anga n.= O';ecti e % >re$ness in t)e affecte$ area

After 8 )ours of nursing inter ention s5t)e -atient !i## er'a#i9e re#ief fro, -ain an$ rate it as 804?fro, @04?.

T)ese $ata can 'e use$ to i$entif" t)e eBtent of t)e -ain as !e## asser e as a 'ase#ineinfor, ation. So,e -eo-#e $en" t)e eB-erience of -ain !)en it is -resent. Attent ion to associate$ sig ns ,a" )e#t)e nurse in

Goa# ,et. After8 )ours of nursinginter enti ons5t)e -atient er'a#i9e$ re#ief fro, -ain an$rate$ it as 804?fro, @04?.

>irrita'i#it" >S)o!s signs of -rotecti e gestures near t)e affecte$ area >Rate$ -ain as @04? in a -ain sca#e of ?14?

rest#essness5 an$ a'i#it" to focus.

e a#uating -ai n.

AAssess for -ro'a'#e cause of -ain.

AAssess -atientCs (no!#e$ge of or -reference for t)e arra" of -ain1re#ief strate gies a ai#a'#e.

Different etio#ogica# factors res-on$ 'etter to $ifferent t)era-ies So,e -atients ,a" 'e una!are of t)e effecti eness of non -)ar,aco#ogic a# ,et)o$s an$ ,a" 'e !i##ing to tr" t)e,5eit)er !it) or instea$ of tra$itiona# ana#gesic ,e$ications. Often a co,'ination of t)era-ies

/e.g.5 ,i#$ ana#gesics !it) $istraction or )eat2,a" -ro e ,ost effecti e I,'a#anc e$ nutrition% #ess t)an 'o$" re6uire,e nts Subjecti ve c#ient eB-resse $ a #ac( of interest in foo$ 'ecause of nausea Objectiv e >Increas e$ ,eta'#ic nee$ $ue to i##ness >Vo,itin g after ,ea#s >Eating #ess t)an +?D of Nausea an$ o,iting are not $iseases5 'ut rat)er are s",-to,s of ,an" $ifferent con$itions5 suc) as infection /Esto,ac) f#uE25 foo$ -oisoning5,otion sic(ness5 o ereating5 '#oc(e$ intestine5 i##ness5 concussion or 'rain in;ur"5 A--en$icitis5 an$ ,igraines. Nausea an$ o,iting can so,eti,es 'e S",-to,s of :ore serious $iseases suc) as 7eart attac(s5 (i$ne" or #i er $isor$ers5 centra# ner ous s"ste, $isor$ers5 'rain tu,ors5 an$ so,efor,s of cancer /)tt-%00!!!.scri'$.co,0$oc08?+F+8 F*0Nutrition1I,'a#ance1Nc-2 Long Term: c#ient !i## not eB-erience !eig)t #oss $uring )er sta" >o'tain an$ recor$ -atientCs !eig)t at sa,e ti,e e er" $a" > o'tain an$ recor$ -atientCs !eig)t at sa,e ti,e e er" $a" > to o'tain ,ost accurate rea$ings >re,o e co er of foo$ tra" 'efore 'ringing it into t)e roo, >su$$en concentrate$ foo$ o$ors t)at co,es !)en t)e co er is re,o e$ can trigger nausea >C#ient $i$ not eB-erience an" !eig)t #oss $uring sta" &C#ient is a'#e to consu,e a$e6uate nutrition of at #east @+D of foo$ at ,ea#ti,es

Short Term: c#ient !i## consu,e at #east @+D of foo$ at ,ea#ti,es

>to o'tain ,ost accurate rea$ings

,ea#s >7"-erac ti e 'o!e# soun$s.G >Pa#e con;uncti a an$ ,ucus ,e,'ran e.G >V0S ta(en as fo##o!s% T% HI.I P% F3 R% 43 B-% 44?0F?