NURSING CARE PLAN

ASSEESSMENT DATA (Subjective & Objective Cues) Objective: Dyspnea: use of accessory muscles for respiration- elevated shoulders. Tachypnea: RR=28cpm O2 saturation= 80% Rales hear upon auscultation on (R) and (L) lung bases. Productive cough noted with yellowish sputum in color and 20 ml in amount collected in an 8-hr shift. Restless NURSING DIAGNOSIS (Problem and Etiology) Ineffective airway clearance related to excessive mucus secretions secondary to inflammation of the lungs. GOALS AND OBJECTIVES Short-term After 15 minutes of nursing interventions, the patient will be able to achieve patent airways as evidence by: Eupnea- absence of use of accessory muscles RR within normal range (12-25cpm) O2 saturation= 90100% Ease in breathing NURSING INTERVENTIONS AND RATIONALE Assessed respiratory rate. Rationale: Provides a basis for evaluating adequacy of ventilation

EVALUATION Goals met. After 15 minutes of nursing interventions, the patient achieved patent airways as evidence by: Eupnea- absence of use of accessory muscles RR within normal range (12-25cpm) O2 saturation= 90100% Ease in breathing

Noted chest movement; use of accessory muscles during respiration Rationale: Use of accessory muscles of respiration may occur in response to ineffective ventilation Auscultated breath sounds. Rationale: noted areas with Presence rales indicate accumulation of secretions and inability to clear airway.

Long-term After 2 day-shift, the patient will demonstrate reduction of congestion as evidence by: Normal breath sounds heard upon auscultation Noiseless respirations

After 2 days of 8 hours duty, the patient demonstrated reduction of congestion as evidence by: Normal breath sounds heard upon auscultation Noiseless respirations

Documented respiratory secretions: character and amount of sputum. Rationale: Expectorations maybe different when secretions are very thick. Maintained patient on moderate high back rest. Rationale: To take advantage of gravity decreasing pressure on the diaphragm. Change position every 2 hours within patients limitation (turning to sides). Rationale: Enhancing drainage to different lung segments. Performed chesttapping. Rationale: To

mobilize secretions from smaller to larger airways for easy expectorations. Kept environment allergen free (e.g., dust, feather pillows, smoke). Rationale: To prevent allergy that may cause further complications.

Dependent: Administered SuloCortef 100 mg IVTT b.i.d. as ordered. Rationale: To suppress inflammatory response and treat inflammation of the lungs.

NURSING CARE PLAN

ASSEESSMENT DATA (Subjective & Objective Cues) Objective: Restlessness Dyspnea: use of accessory muscle in respirations elevated shoulders Tachypnea: RR=28cpm O2 saturation= 80% Rales hear upon auscultation on (R) and (L) lung bases NURSING DIAGNOSIS (Problem and Etiology) Impaired gas exchange related to collection of secretions affecting oxygen exchange across alveolar membrane secondary to inflammation of lungs. GOALS AND OBJECTIVES Short-term After 15minutes of nursing interventions, the patient will demonstrate improve ventilation as evidence by:

NURSING INTERVENTIONS AND RATIONALE Independent:

EVALUATION Goals met. After 8 hours of nursing interventions, the patient demonstrated improve ventilation as evidence by: Absence of symptoms of respiratory distress (dyspnea, tachypnea, restlessness) O2 saturation within normal range

Absence of symptoms of respiratory distress (dyspnea, tachypnea, restlessness) O2 saturation within normal range

Monitored skin and mucous membrane color Rationale: Duskiness and central cyanosis indicate advanced hypoxemia Elevated head of the bed, assist patient to assume position to ease work of breathing. Rationale: Oxygen delivery may be improved by upright suctioning Auscultate breath sounds, noting areas of decreased air-flow or presence of

Long-term At the end of 2 day-shift, the patient will demonstrate reduction of congestion as evidence by: Normal breath sounds heard upon auscultation Noiseless respirations

After 2 days of 16 hours duty, the patient demonstrated reduction of congestion as evidence by: Normal breath sounds heard upon auscultation Noiseless respirations

adventitious sound Rationale: Presence of wheezes may indicate bronchospasm/ retained secretions Change position every 2 hours within patients limitation (turning to sides). Rationale: Enhancing drainage to different lung segments. Provide quiet environment to allow the patient to relax Rationale: External stimuli may prevent relaxation or inhibit sleep.
Administered SuloCortef 100 mg IVTT b.i.d. as ordered. Rationale: To suppress inflammatory response and treat inflammation of the lungs.

Dependent:

NURSING CARE PLAN

ASSEESSMENT DATA (Subjective & Objective Cues) Risk factors: Physical immobilization Impaired metabolic state NURSING DIAGNOSIS (Problem and Etiology) Risk for Impaired Skin Integrity related to limited mobility to GOALS AND OBJECTIVES Short term: After 2-4 of nursing interventions, the SO will be able to verbalize understanding of individual factors that contribute to possibility of skin integrity impairment Within 8 hours of nursing interventions, the patient will be free of skin breakdown as evidence by: NURSING INTERVENTIONS AND RATIONALE Independent: Kept bed linens dry and wrinkle-free Rationale: To avoid skin breakdown.

EVALUATION Goals met.

Assisted in positioning Rationale: To prevent friction or shear injury. Provided protection by use of pillows and foam mattress Rationale: To increase circulation and limit excessive tissue pressure. Turned to sides every 2 hours. Rationale: To alleviate prolonged tissue pressure. Provided active and passive ROM

After 2-4 of nursing interventions, the SO verbalized understanding of individual factors that contribute to possibility of skin integrity impairment Within 8 hours of nursing interventions, the patient was free of skin breakdown as evidence by:

Intact skin integrity absence of lesions (newly developed) Long term: After 2 days of 16 hours duty of NI the client and significant others will be able to demonstrate behaviors to prevent

Intact skin integrity absence of lesions (newly developed) After 2 days of 16 hours duty of NI the client and significant others demonstrated behaviors to prevent skin breakdown

Skin breakdown.

exercises Rationale: to enhance circulation and maintain muscle strength and tone.

Inspected skin surfaces routinely and observing for any reddened areas. Rationale: To determine impending signs and symptoms that might progress to skin breakdown. Explained risks for skin breakdown that will predispose patient to infection. Rationale: For patient and significant others foresee impending problem and gain their cooperation. Suggested use of water based lotion Rationale: To decrease irritable itching. Instructed family to maintain clean, dry

clothes, preferably cotton fabric (any Tshirt). Rationale: Skin friction caused by stiff or rough clothes leads to irritation of fragile skin and increases risk for infection. Instructed family to cut and file nails regularly. Rationale: Long and rough nails increase risk of skin damage.

NURSING CARE PLAN

ASSEESSMENT DATA (Subjective & Objective Cues) Subjective Cues: .dili sya ka istorya sukad sa pagka disgrasya niya as verbalized by the mother. Objective Cues: Inability to articulate Absence of eye contact Lack of interest in communication NURSING DIAGNOSIS (Problem and Etiology) GOALS AND OBJECTIVES NURSING INTERVENTIONS AND RATIONALE Independent: Noted results of CT scans. Rationale: To determine causative factors. Established good nurse patient relationship Rationale: To establish rapport and convey interest and concern. Kept communication simple, speaking in short sentences, using appropriate words. Rationale: Long and complex sentences will confuse patient. Maintained eye contact. Rationale: To get patients attention. Used gestures congruent to words when speaking to EVALUATION Goals met. At the end 8 hours nursing interventions, the patient: Displayed interest in communication Established method of communication in which needs can be expressed. Demonstrated eye contact to his healthcare providers

Impaired Verbal At the end 8 hours nursing Communication related to interventions, the patient alteration of the CNS (hyper will be able to: densities of R caudate Display interest in nucleus) secondary to communication traumatic brain injury Establish method of communication in which needs can be expressed. Demonstrate eye contact to his healthcare providers

patient. Rationale: To provide reinforcement to the spoken words for easy understanding. Taught patient to use other means of communication such as: nodding and shaking of head to indicate yes or no, signing, and writing to a paper. Rationale: To minimize patients frustration and promote understanding of patient Provided silent environment. Rationale: Noise may interfere with communication process. Dependent/Collaborative: Referred to speech/language therapist. Rationale: To treat speech disorder.

NURSING CARE PLAN

ASSEESSMENT DATA (Subjective & Objective Cues) Subjective: Gakalipong siya kung mobangon siya, as verbalized by the mother. Objective:

NURSING DIAGNOSIS (Problem and Etiology)

GOALS AND OBJECTIVES

Staggering gaitinability to maintain balance Lies down for almost all times Muscle weakness in extremities Othostatic hypotension noted (from 120/80mm Hg in standing position to 90/60 upon sitting)

Impaired physical mobility Short-term related to inability to After 8 hours of nursing maintain balance secondary intervention, the patient will: to alteration in CNS. Demonstrate techniques that will enable resumption of activities as evidence by following the instruction given for repositioning, normal ROM, standing, and other activities. After 2 day-shift of duty, the patient will Demonstrate increase strength as evidence by repeating the activities done in the previous day.

NURSING INTERVENTIONS AND RATIONALE Independent: Assisted patient to reposition self on a regular schedule. Rationale: To promote optimal level of functioning, promote muscle strength and prevent further complications. Instructed use of side rails in changing position. Rationale: To promote optimal level of functioning.

EVALUATION Goals met. After 8 hours of nursing intervention, the patient:

Demonstrated techniques that will enable resumption of activities as evidence by following the instruction given for repositioning, normal ROM, standing, and other activities. After 2 day-shift of duty, the patient demonstrated increase strength as evidence by repeating the activities done in the previous day.

Assisted with normal range of motion exercises and function of extremity. Rationale: To maintain muscle

tonicity and strength and prevent atrophy.

Allow patient to sit at the edge of the bed for 3 minutes with feet dangling over the side of bed before assisting patient to stand. Rationale: To encourage venous return for proper perfusion of the brain. Thus preventing dizziness when standing.

Encouraged progressive activities with adequate rest on intervals. Rationale: To reduce fatigue.

Provide safety measure in all activities, including environmental management and fall prevention. Rationale: To

prevent accident and fall.