NURSING CARE PLAN Name of Patient: JB Age:46 y.o. Ward/Bed No.:FMSW 1 Attending Physician: Dr.

S Impression/Diagnosis: Atelectasis R lung; cant rule out mass; t/c consolidation pneumonia, PTB 4 Nursing Interventions Independent Assess airway patency. Rationale Evaluation

Clustered Cues March 22,2011 No subjective cues:client unable to verbalize due to the presence of NG and ET tube. Difficulty of breathing Excessive secretions in airway Inability to expectorate secretions effectively. Presence of crackles,wheezing Use of mechanical

Nursing Diagnosis Ineffective airway clearance related to

Rationale Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway.

Outcome criteria

The client will be able to display patent airway with reduced abnormal breath sounds ,absence of dyspnea ,diminished secretions

Obstruction may be caused by accumulation of secretions, mucous plugs, hemorrhage, bronchospasm, and problems with the position of tracheostomy or ET tube. Symmetrical chest movement with breath sounds throughout lung fields indicates proper tube placement and unobstructed airflow. Lower airway obstruction, such as pneumonia or atelectasis, produces changes in breath sounds, such as rhonchi and wheezing.

Evaluate chest movement and auscultate for bilateral breath sounds.

Monitor ET tube placement. Note lip line marking and compare with desired placement. Secure tube carefully with tape or tube holder. Obtain assistance when retaping or repositioning tube.

The ET tube may slip into the right main-stem bronchus, thereby obstructing airflow to the left lung and putting client at risk for a tension pneumothorax.

Ventillator

Assess rate and depth of respirations and chest movement. Monitor for signs of respiratory failure such as cyanosis and severe tachypnea.

Tachypnea, shallow respirations, and asymmetric chest movement are frequently present because of discomfort of moving chest wall or fluid in lung. When pneumonia is severe, the client may require endotracheal intubation and mechanical ventilation to keep airways clear. Increased amounts of colorless (or blood-streaked) or watery secretions are normal initially and should decrease as recovery progresses. Presence of thick, tenacious, bloody, or purulent sputum suggests development of secondary problemsfor example, dehydration, pulmonary edema, local hemorrhage, or infectionthat require correction or treatment. 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 expiration in response to fluid accumulation, thick secretions, and airway spasm or obstruction. Keeping the head elevated lowers diaphragm, promoting chest expansion, aeration of lung segments, and mobilization secretions to keep the airway clear.

Observe amount and character of sputum and aspirated secretions. Investigate changes, as indicated.

Auscultate lung fields, noting areas of decreased or absent airflow and adventitious breath sounds, such as crackles and wheezes.

Elevate head of bed; change position frequently.

Suction as needed when client is experiencing respiratory distress, limiting duration of suction to 15 seconds or less. Choose appropriate suction catheter. Suction intermittently.

Stimulates cough or mechanically clears airway in client who is unable to do so. Suctioning should not be routine, and duration should be limited to reduce hazard of hypoxia. Suction catheter diameter should be less than 50% of the internal diameter of the ET or tracheostomy tube for prevention of hypoxia.

Collaborative Assist with and monitor effects of nebulizer treatments. Perform treatments between meals and limit fluids when appropriate.

Facilitates liquefaction and removal of secretions. Coordination of treatments, schedules, and oral intake reduces likelihood of vomiting with coughing and expectorations. Aids in reduction of bronchospasm and mobilization of secretions.

Administer medications, as indicated, for example mucolytic (acetylcystein) and bronchodilator (Salbutamol). Provide supplemental fluids such as IV and humidified oxygen.

Fluids are required to replace losses, including insensible, and aid in mobilization of secretions. Follows progress and effects of disease process and therapeutic regimen, and facilitates necessary alterations in therapy.

Monitor serial chest x-rays and ABGs.

Name of Student: Clinical Instructor: