NURSING CARE PLAN

ASSESMENT (+) crackle Presence of tracheobronc hial secretions Presence of ET tube attached to mechanical ventilator RR: 28 cpm Pale, cool, dry skin DIAGNOSIS Ineffective airway clearance R/T presence of trachea bronchial secretions PLANNING After 8 hours of rendering an effective nursing intervention the patient will be able to improve/ maintain clear airway INTERVENTION RATIONALE EVALUATION Positioned on modified high To open and maintain airway At the end of 8 hours the back rest clearance; promote lung goals are partially met expansion since the patient was able to improved clear airway. Suction secretions as To clear the airway from the necessary secretions

Turn patient to sides every To help mobilize secretions two hours and can be a powerful means of maintain lung health Back tapping nebulization post To help mobilize secretions and aid in spreading the medication Rest will prevent fatigue and decrease oxygen demands for metabolic demands

Provide adequate rest periods

Collaborative: Administer acetylcysteine To liquify secretions 600 mg 1 tab + glass H2O BID as ordered Administer Salbutamol 1 To promote bronchodilation neb q8

CUES SUBJECTIVE OBJECTIVE (+) rales

NURSING DIAGNOSIS

GOALS/OBJECTIVES At the end of 8 hours of good nursing intervention the patient will be able to demonstrate improved ventilation and adequate oxygenation of tissues by ABGs within clients normal limits and absence of respiratory distress.

NURSING INTERVENTION INDEPENDENT: Elevate head of bed and position patient appropriately. Change position frequently and encourage deep breathing exercises. Reinforce need for adequate rest periods.

RATIONALE

crackles/ Impaired Gas Exchange related to ventilation Presence of perfusion tracheobronchial imbalance secretions Presence of ET tube attached to mechanical ventilator RR: 28 cpm Pale, cool, dry skin Labs: Increased PCO2 Increased PO2 Increased HCO3 Increased pH

To maintain airway. To promote optimal lung expansion

EVALUATION At the end of 8 hours goals are partially met since the patient was able to demonstrate improved oxygenation

Rest will prevent fatigue and decrease oxygen demands for metabolic demands To promote relaxation and

Provide a calm and quiet environment DEPENDENT: O2 administration via Mechanical Ventilator attached to ET tube

To increase oxygen availability.

ASSESMENT Presence of bed sores at the back upper right area of the shoulder, upper right area of the pelvis and on both heels Pale, skin cool, dry

DIAGNOSIS Risk infection for

PLANNING Within the shift the patient will achieved timely wound healing and to minimize risk of infection

INTERVENTION

RATIONALE

EVALUATION After the shift, the goals are partially met since the patient was able to minimize risk of infection patient was free from infection achieved time wound healing.

Do proper To avoid contamination wound care Always maintain To avoid spreading of aseptic microorganism techniques when performing procedures Replace FBC as To prevent ascending necessary infection Turn to sides To avoid formation of every two hours another pressure sores Keep skin clean Moisture leads to skin and dry breakdown. By keeping the skin dry and clean you are reducing moisure and reducing the amount of bacteria on the skin that \ may cause an infection. Collaborative: Administered To promote timely wound calmoseptine healing and combat ointment to bed infection sores TID

Presence of ET tube, nasogastric tube, and FBC attached to urobag