NURSING CARE PLAN

Name: Address: Chief Complaint: ASSESSMENT Nursing Diagnosis Age: Clinical Impression: PLANNING Goals & Desired Outcome At the end of my shift, after medical and nursing intervention the patients airway will slightly be cleared as evidenced by patient will have normal rate and depth of breathing, will have normal breath sounds, will less use accessory muscle for breathing and will not anymore experience dyspnea. Sex: Male Rm. No.: Religion: Bed No.: Date of Admission: EVALUATION

Cues/Evidence

Scientific Rationale

IMPLEMENTATION Nursing Order/Action Rationale for Action Assess rate/depth of respirations and chest movement. Tachypnea, shallow respirations, and asymmetric chest movement are frequently present because of discomfort of moving chest wall and/or fluid in lung. Decreased airflow occurs in areas consolidated with fluid. Bronchial breath sounds (normal over bronchus) can also occur in consolidated areas. Crackles, rhonchi, and wheezes are heard on inspiration and/or expiration in response to fluid accumulation, thick secretions, and airway spasm/obstruction. Lowers diaphragm,

Subjective data:

Ineffective airway Infectious agents clearance related to increased sputum Patients normal flora production in response altered to respiratory infection secondary to pneumonia Inflammatory reaction Objective: as evidenced by occurs in the alveoli - Changes in Restlessness, Presence of producing an exudates rate, depth sputum, Difficulty of that interferes with the breathing, RR- 63, SpO2 - diffusion of oxygen and of Positive chest carbon dioxide respirations. 78, retractions, Pale, Using - Abnormal ventilatory support. White blood cells breath migrate into the alveoli sounds - Use of Secretions and mucosal edema causes partial accessory occlusion of the muscles bronchi making the - Dyspnea lungs not adequately - Use of ventilated mechanical ventilator Decrease in alveolar

Auscultate lung fields, noting areas of decreased/absent airflow and adventitious breath sounds, e.g., crackles, wheezes.

oxygen tension Bronchospasm Altered airway ***MSN by Brunner and Suddarth p.525

Elevate head of bed, change position frequently.

promoting chest expansion, aeration of lung segments, mobilization and expectoration of secretions. Stimulates cough or mechanically clears airway in patient who is unable to do so because of ineffective cough or decreased level of consciousness.

Suction as indicated (e.g., frequent or sustained cough, adventitious breath sounds, desaturation related to airway secretions). Monitor serial chest x-rays, ABGs, pulse oximetry readings.

Follows progress and effects of disease process/therapeutic regimen, and facilitates necessary alterations in therapy.

Dependent: Administer medications as indicated: mucolytics, expectorants, bronchodilators,

Aids in reduction of bronchospasm and mobilization of secretions. Analgesics are given to improve cough effort by reducing discomfort, but should be used cautiously

analgesics.

because they can decrease cough effort/depress respirations. Fluids are required to replace losses (including insensible) and aid in mobilization of secretions. Note: Some studies indicate that room humidification has been found to provide minimal benefit and is thought to increase the risk of transmitting infection.

Provide supplemental fluids, e.g., IV, humidified oxygen, and room humidification.

Cues/Evidence

ASSESSMENT Nursing Diagnosis

Scientific Rationale

PLANNING Goals & Desired Outcome After 3 days of rendering nursing and medical intervention the patient will demonstrate improved ventilation and oxygenation of tissues by ABGs within patients acceptable range and absence of symptoms of respiratory distress, will not experience dyspnea and tachycardia, no nasal flaring and will have normal rate, rhythm and depth of breathing.

IMPLEMENTATION Nursing Order/Action Rationale for Action Maintain client airway. Place client in position of comfort with head of bed elevated 30 to 45 degrees. Monitor respiratory rate and depth. Note use of accessory muscles or work of breathing. Elevating the head of bed enhances lung expansion and reduces respiratory effort.

EVALUATION

Subjective data:

Impaired Gas Exchange r/t collection of secretions affecting oxygen exchange across alveolar membrane.

Pneumonia

Objective: - Dyspnea - Tachycardia - Nasal flaring - Abnormal rate, rhythm and depth of breathing

Inflammation of the parenchyma of the lung (that is, the alveoli)

Abnormal alveolar filling with fluid (consolidation and exudation)

cough, chest pain, fever, and difficulty in breathing.

Impaired gas exchange

Rapid, shallow respirations occur because of hypoxemia, stress, and circulating endotoxins. Hypoventilation and dyspnea reflect ineffective compensatory mechanisms and are indications that ventilatory support is needed. Respiratory distress and the presence of adventitious

Note crackles, wheezes, and areas of decreased or

absent ventilation.

Reposition frequently and suction, as indicated.

sounds indicators pulmonary congestion, interstitial edema, atelectasis. -

are of

and

Good pulmonary toilet is necessary for reducing ventilation/ perfusion imbalance and for mobilizing and facilitating removal of secretions to maximize gas exchange.

Cues/Evidence

ASSESSMENT Nursing Diagnosis

Scientific Rationale

PLANNING Goals & Desired Outcome

IMPLEMENTATION Nursing Order/Action Rationale for Action

EVALUATION

Subjective: N/A

Ineffective breathing pattern related to immature neurologic and delayed pulmonary development

Objective: With ET tube connected to mechanical ventilator RR: 44 cycles/ min O2 saturation of 91%

A premature lung is structurally underdeveloped for postnatal life. A deficiency in surfactant, which functions to decrease the surface tension within the alveoli. Without surfactant, the infant experiences diffuse atelectasis, decreased pulmonary compliance, ventilation perfusion mismatching, and significant increase in the work of breathing. Source: http://www.scribd.co m/doc/96101992/NcpNewborn

After 30 minutes of INDEPENDENT: nursing interventions, the infant will experience (1) assess RR an effective breathing pattern pattern as manifested by

and

Infants RR is between 40 and 60 Infant will experience (2) Provide respiratory no apnea assistance as needed. O2 saturation will be maintained in normal range (90-94) (3) position infant on side with a rolled blanket behind his back (4) provide tactile stimulation during periods of apnea (5) Position patient to facilitate optimum breathing patterns. (6) Maintain airway clearance.

(1) assessment provides information about neonates ability to initiate and sustain an effective breathing pattern (2) assistance helps the newborn by clearing the airway and promoting oxygenation (3) lying on the side position to facilitate breathing (4)stimulation of the sympathetic nervous system increases respiration (5) Allows gravity to assist in lowering the diaphragm, and provides greater chest expansion (6) Maintains a patent airway for gas exchange

Cues/Evidence

ASSESSMENT Nursing Diagnosis

Scientific Rationale

PLANNING Goals & Desired Outcome

IMPLEMENTATION Nursing Order/Action Rationale for Action 1. Assess mothers perception and knowledge about breastfeeding and extent of instruction that has been given. 2. Give emotional support to mother and accept decision regarding cessation/ continuation of breast feeding. 3. Demonstrate use of manual pistontype breast pump. 4. Review techniques for storage/use of expressed breast milk 5. Determine if a routine visiting schedule or advance warning can be provided 1. To know what the mother already knows and needed to know. 2. To assist mother to maintain breastfeeding as desired. 3. aid in feeding the neonate with breast milk without the mother breastfeeding the infant. 4. To provide optimal nutrition and promote continuation of breastfeeding process 5. So that infant will be hungry/ ready to feed 6. To promote successful infant feeding

EVALUATION

Subjective data:

Objective: - The newborn is diagnosed with a disease - The newborn is separated from his mother - The mother unable to provide breast milk to newborn continuously.

Interrupted breastfeeding related to neonates present illness as evidenced by separation of mother to infant

Abnormal condition of Short-term: After 3 hours the newborn of nursing intervention and health teachings the mother will identify and Need of special demonstrate techniques intervention and close to sustain lactation until monitoring. breastfeeding is initiated Long Term: After 3 days Admission of newborn of NI, the mother shall to NICU still be able to identify and demonstrate techniques to sustain Separation from the lactation and identify mother techniques on how to provide the newborn with breast milk. Interrupted breastfeeding

6. Provide privacy, calm surroundings when mother breast feeds. 7. Recommend for infant sucking on a regular basis 8. Encourage mother to obtain adequate rest, maintain fluid and nutritional intake, and schedule breast pumping every 3 hours while awake

7. Reinforces that feeding time is pleasurable and enhances digestion. 8. to sustain adequate milk production and breast feeding process