NURSING CARE PLAN

Patient Name: J.A. Age/Gender: 93 yrs. old / F Diagnosis: CAP with risk moderate HPN Ineffective airway clearance ASSESSMENT DIAGNOSIS SUBJECTIVE DATA: Nurse, nahihirapan akong huminga ngayon as verbalized by patient. OBJECTIVE DATA: Use of accessory muscle. Dyspnea Fatigue (+) alar flaring (+) intercostals retractions (+) wheezes @ both lung field (+) labored breathing V/S taken as follows: T: 37.3*C P: 80 bpm R: 31 cpm Bp: 120/80mmHg Ineffective airway clearance r/t increase bronchial secretion secondarty to pneumonia.

PLANNING After 8 hours of rendering of nursing intervention the patient will manifest effective breathing pattern.

INTERVENTION Independent: Elevate head of the bed, change position frequently.

RATIONALE

EVALUATION Goal Met:

Lowers diaphragm, promoting chest expansion and expectoration of secretions. Deep breathing facilitates maximum expansion of the lungs and smaller airways. Coughing is a natural self-cleaning mechanism. Splinting reduces chest discomfort, and an upright position favors deeper, more forceful cough effort.

After 8hours of rendering of nursing intervention patient able to manifest effective breathing pattern.

Assist patient with deep breathing exercises.

Demonstrate or help patient learn to perform activity like splinting chest and effective coughing while in upright position.

Force fluids to at least Fluids especially 3000 ml per day and warm liquids aid in offer warm, rather mobilization and than cold fluids. expectoration of secretions.

Auscultating patients chest

To monitor for the presence of abnormal breath sounds

Provide chest and back clapping with vibration

Chest physiotheraphy facilitates the loosening of secretions

Collaborative: Administers and titrates oxygen therapy as prescribed. Administer medications as prescribe: mucolytics or expectorants. Provide supplemental fluids. Support adequate body oxygenation of patient

Aids in reduction of bronchospasm and mobilization of secretions. Fluids are required to replace losses and aid in mobilization of secretions.

Assist respiratory therapist in performing nebulization of the patient

Nebulization is a favourable route of administering bronchodilators and aid in expectorating secretions, hence patients breathing