Cellulitis is a common, potentially serious bacterial skin infection. Cellulitis appears as a swollen, red area of skin that feels hot and tender, and it may spread rapidly. Skin on lower le…Full description
Nursing Care Plan for ESRD
These NCP are only some of the possible NCP's for a premature infant.. I only have few objective cues, so feel free to add some when you make your own NCP... For the interventions i should h…Full description
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Nursing Care Plan forFull description
.,this is a sample nursing care plan for patients with cerebral infarction (stroke). I have used this is our case study presentation (individual). It consist of 3 nursing care plan. Check it…Full description
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NURSING CARE PLAN FOR A PATIENT WITH PLEURAL EFFUSION ASSESSMENT
Subjective: “Ubo ako ng ubo” as verbalized by the patient.
Objective: • • • •
Cough Restlessness Pale With left side CTT connected to thorabottle.
Vital signs taken: • •
•
T: 36.9 PR: 105 bpm (tachycardia ) RR: 22 cpm
DIAGNOSIS
•
Ineffective airway clearance related to retained secretions.
PLANNING
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After 8 hours of nursing intervention, the patient will be able to maintain airway patency and clear secretions readily.
INTERVENTION
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Assess respirations: note quality, rate, pattern, depth, and breathing effort.
Monitor vital signs.
RATIONALE
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Both rapid, shallow breathing patterns and hypoventilat ion affect gas exchange. With initial hypoxia and hypercapnia, blood pressure, heart rate, and respiratory rate all rise. As the hypoxia and/or hypercapnia become more severe, BP may
EVALUATION
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Goal met. After 8 hours of nursing intervention, the patient is able to maintain airway patency and clear secretions readily.
•
BP: 110/80 mmHg
drop, heart rate tends to continue to be rapid with arrhythmias, and respiratory failure may ensue with the patient unable to maintain the rapid respiratory rate.
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Assess for changes in orientation and behavior.
Restlessness is an early sign of hypoxia. Chronic hypoxemia may result in cognitive changes such as memory changes.
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Assess patient’s ability to cough effectively to clear secretions. Note quantity, color, and consistency of sputum. Maintain oxygen administrati on device as ordered, attempting to maintain oxygen saturation at 90% or greater. Position with proper body alignment
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•
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Retained secretions impair gas exchange.
This provides for adequate oxygenation.
This promotes
for optimal respiratory excursion.
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Anticipate need for intubation and mechanical ventilation if patient is unable to maintain adequate gas exchange.
Teach the patient appropriate deep breathing and coughing techniques.
lung expansion and improves air exchange.
•
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Early intubation and mechanical ventilation are recommende d to prevent full decompensat ion of the patient.
These facilitate adequate air exchange and secretion
