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  • Word Ncp.......... Tetanus

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    Yvounne Ananias Bautista RN
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    The patient presented with pain in the jaw rated 5/10 with facial grimacing, slight diaphoresis, and trismus. After 2 hours of nursing interventions including analgesia, back rubs, and quiet environment, the patient's pain score decreased to 2 and they were sleeping comfortably. The second patient had difficulty breathing as evidenced by difficulty speaking, occasional trismus, slight cyanosis, rapid shallow breathing at 35 bpm, and oral secretions. Diagnosis was ineffective airway clearance. After 2 hours of interventions like elevating the head and deep breathing exercises, the patient's respiratory rate stabilized at 21 bpm and their airway patency was maintained.

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    Word Ncp..........Tetanus

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    The patient presented with pain in the jaw rated 5/10 with facial grimacing, slight diaphoresis, and trismus. After 2 hours of nursing interventions including analgesia, back rubs, and quiet environment, the patient's pain score decreased to 2 and they were sleeping comfortably. The second patient had difficulty breathing as evidenced by difficulty speaking, occasional trismus, slight cyanosis, rapid shallow breathing at 35 bpm, and oral secretions. Diagnosis was ineffective airway clearance. After 2 hours of interventions like elevating the head and deep breathing exercises, the patient's respiratory rate stabilized at 21 bpm and their airway patency was maintained.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
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    351 views3 pages

    Word Ncp.......... Tetanus

    Uploaded by

    Yvounne Ananias Bautista RN
    The patient presented with pain in the jaw rated 5/10 with facial grimacing, slight diaphoresis, and trismus. After 2 hours of nursing interventions including analgesia, back rubs, and quiet environment, the patient's pain score decreased to 2 and they were sleeping comfortably. The second patient had difficulty breathing as evidenced by difficulty speaking, occasional trismus, slight cyanosis, rapid shallow breathing at 35 bpm, and oral secretions. Diagnosis was ineffective airway clearance. After 2 hours of interventions like elevating the head and deep breathing exercises, the patient's respiratory rate stabilized at 21 bpm and their airway patency was maintained.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
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    of 3

    ASSESSMENT Subjective: sumasakit ang panga ko As verbalized by the patient Objective: With facial grimace with pain score

    re of 5 out of 10 >slightly irritated Slightly diaphoretic >With trismus noted with abdominal rigidity

    DIAGNOSIS Acute Pain related to uncontrolled muscle spasm and involuntary muscle contraction

    PLANNING After 2 hours of nursing intervention patients pain Will be relieved and controlled.

    INTERVENTION Assess predisposing factors to pain Monitor vital signs Ask the patient to describe the pain Encourage to have diversional activities Adviced to have comfort measures sucha s back rub Administer analgesic Provide a quiet and non stimulating environment .

    RATIONALE To know the etiology of pain Usually altered in acute pain To determine how in pain the patient is. To divert the attention of the patient while in pain To provide non pharmacological pain management to relieveepain To prevent stimulation

    EVALUATION After 2 hours of nursing intervention the Patients pain score 0f 5 decreased to 2 ( moderate to mild pain) seenS patient comfortably sleeping

    ASSESSMENT SUBJ: nahihirapan akong huminga as verbalized by the patient. OBJ: With difficulty vocalizing words >with trismus noted occassionally >Slighly cyanotic >with rapid and shallow breathing >Fast breathing- 35bpm >with oral mucous secretions

    DIAGNOSIS ineffective Airway Clearance related to airway spasm and neuromuscular dysfunction

    PLANNING After 2 hours of nursing intervention, patient will be able to maintain airway patency

    INTERVENTION Position the client appropriately by elevating of head bed encourage deep breathing exercise

    RATIONALE For maximum lung expansion To maximize effort and mobilized secretions

    EVALUATION Goal met. Patient was able to maintain adequate airway patency as avidenced by stabilized Respiratory rate of 21 bpm

    Monitor respirations and breath sounds Position the patient by elevating the bed Insert oral airway in severe cases as ordered

    To assess changes and note complications

    To maintain anatomic position of tongue and natural airway

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