NAME: Carandang, Leilani BED NO.

: 3
AGE: 35 yrs old. ATTENDING PHYSICIAN: Dr. M. Lim
DIAGNOSIS: Bronchiectasis, Cor Pulmonale

DATE & NURSING OBJECTIVE OF

CUES NEED NURSING INTERVENTIONS EVALUATION
TIME DIAGNOSIS CARE

June 26, 2005 Subjective: A Ineffective airway At the end of my 8 1. Assess rate/depth of respirations and chest June 26, 2005
@ No subjective C clearance related to hour span of care, movements. @
3:00 pm cue since T increased mucus my patient will be R: Tachypnea, shallow respirations, and asymmetric 11:00 pm
patient attached I production secondary able to have chest movement are frequently present because of
to mechanical V to Bronchiectasis. improved airway discomfort. GOAL Partially
ventilator. I clearance as 2.Auscultate lung fields, noting areas of met.
T Rationale: evidenced by: decreased/absent airflow and adventitious breath After my 8 hour span
Objective: Y Bronchiectasis is an sounds, e.g., crackles, wheezes. of care, my patient
> Vital signs extreme form of a. Vital Signs R: Decreased airflow occurs in areas consolidated with had partially
revealed: E bronchitis that causes within normal fluid. Bronchial breath sounds can also occur in manifested an
( RR – 28) X permanent abnormal values ( RR: consolidated areas. Crackles, rhonchi, and wheezes are improved airway
cycles/min E dilation and distortion 16 – 20 heard on inspiration and /or expiration in response to clearance since, she
PR – 96 bpm R of the bronchi and cycles/min ; fluid accumulation, thick secretions, and airway spasm/ was not dyspneic
> unproductive C bronchioles. During PR: 80 – 90 obstruction. already but her Vital
cough noted I the exposure of bpm) 3. Note presence of sputum; assess quality, color, signs were still above
> nasal flaring S infection, it triggers
noted E the cascades of
> difficulty and inflammatory
shallow P mediators ( histamine,
breathing noted A bradykinins,
T leukotrienes ant etc.)
> abnormal T making the airway
breath sounds E hyperresponsive that
noted upon R causes increased
auscultation; N mucus secretions by
+ crackles goblet cells. As
+ wheeze secretions accumulate
+ rhonchi in the bronchial walls,
> + use of it alters the breathing
accessory pattern making it
muscles for ineffective.
breathing noted Bibliography:
> with Black, J. et al.
nebulization of Medical – Surgical
Salbutamol 3 Nursing.7th edition.
doses every 4 Elsevier
hour. Saunders.Copyright
b. Absence of amount, odor, and consistency. normal ( RR: 26
dyspnea and R: This may be a result of infection, bronchitis, or other cycles/min; PR: 96
shallow condition. A sign of infection is discolored sputum (no bpm ) and still,
breathing longer clear or white); an odor may be present. abnormal breathing
c. Clear breath sounds noted with
sounds. 4. Assist patient to assume position of comfort, e.g. ( +) use of accessory
elevate head of the bed. muscles for
R: Lowers diaphragm, promoting chest expansion, breathing.
aeration of lung segments, mobilization and
expectoration of secretions. Prepared by:
5.Assist with / monitor effects of nebulizer treatments
and other respiratory physiotherapy. Filbert A.
6. Suction secretions as indicated and tolerated by Silvestre,St.N.
patient.
R: Suctioning removes secretions that causes clogging
in the airway.
R: Facilitates liquefaction and removal of secretions.
7. Administer medications as indicated: mucolytics,
expectorant, bronchodilators, analgesics, antibiotics.
R: Aids in reduction of bronchospasm and mobilization
of secretions. Analgesics are given to improve cough
effort by reducing discomfort, but should be used
> with IVF of 2005. P .1830. cautiously because they can decrease cough
PNSS 1L @ effort/depress respirations.
KVO rate 8. Provide supplemental fluids , e.g., IV, humidified
infusing well @ oxygen, and room humidification.
right subclavian R: Fluids are required to replace losses ( including
vein with side insensible ) and aid in mobilization of secretions.
drip of Vitrimiz
1L @ 42 ml/hr 9. Assist patient with frequent deep – breathing
infusing well @ exercises. Demonstrate / help patient learn to perform
left cephalic activity, e.g. splinting chest and effective coughing
vein while in upright position.
R: Deep breathing facilitates maximum expansion of
> with the lungs / smaller airways. Coughing is a natural self –
endotracheal cleaning mechanism, assisting the cilia to maintain
tube attached to patent airways. Splinting, reduces chest discomfort,
mechanical and upright position favors deeper, more forceful
ventilator with cough effort.
respiratory set – 10. Assess and document the patient’s respiratory
up. status.
> on MHBR R: Assessment of the respiratory status provides
> with pulse baseline data to evaluate the efficacy of nursing
oximeter; with interventions.
O2 set of 95% 11.Monitor serial chest X – rays, ABG’s, pulse
oximetry readings.
R: Follows progress and effects of disease process/
therapeutic regimens, and facilitates necessary
alterations in therapy.
12. Keep environmental pollution to a minimum,e.g.
dust, smoke and feather pillows, according to
individual situation.
R: Precipitators of allergic type of respiratory reactions
that can trigger/exacerbate onset of acute episode.
 Criteria:
Bibliography – 5%
Promptness – 5%
Cues/Needs – 20%
Nsg. Diagnosis – 15%
Objectives – 10%
Nsg. Intervention – 40%
Evaluation – 5%

100%

Nursing Care Plan

In Partial Fulfillment of the Requirements in RLE

Submitted to:
Johannes Quindoy, RN
Clinical Instructor

Submitted by:
Hannah Aquino, St.N.
BSN – 3G

November 30,2005