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Rab Dino S/O Mola Bux, a 50-year-old male farmer from Sakrand, presented with bronchitis and difficulty breathing. His assessment found rhonchi, ineffective cough, and signs of respiratory distress. His nursing care plan aimed to improve his ventilation and oxygenation within 8 hours through interventions like respiratory monitoring, positioning, breathing exercises, and expectoration assistance. Long term goals were for adequate oxygenation to meet self-care needs and normal vital signs without respiratory distress symptoms.
Rab Dino S/O Mola Bux, a 50-year-old male farmer from Sakrand, presented with bronchitis and difficulty breathing. His assessment found rhonchi, ineffective cough, and signs of respiratory distress. His nursing care plan aimed to improve his ventilation and oxygenation within 8 hours through interventions like respiratory monitoring, positioning, breathing exercises, and expectoration assistance. Long term goals were for adequate oxygenation to meet self-care needs and normal vital signs without respiratory distress symptoms.
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Rab Dino S/O Mola Bux, a 50-year-old male farmer from Sakrand, presented with bronchitis and difficulty breathing. His assessment found rhonchi, ineffective cough, and signs of respiratory distress. His nursing care plan aimed to improve his ventilation and oxygenation within 8 hours through interventions like respiratory monitoring, positioning, breathing exercises, and expectoration assistance. Long term goals were for adequate oxygenation to meet self-care needs and normal vital signs without respiratory distress symptoms.
Copyright:
Attribution Non-Commercial (BY-NC)
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Als DOC, PDF, TXT herunterladen oder online auf Scribd lesen
DIAGNOSIS Ineffective SHORT TERM: • Assess respiratory rate, • Useful in evaluating the • Patient SUBJECTIVE: airway After 8 hours of depth. Note use of accessory degree or respiratory distress display clearance nursing interventions muscles, pursed lip and chronicity of the disease improved I’m having related to the patient will: breathing, Inability to speak. process. ventilation and difficulty excessive, • Demonstrate • Elevate head of the bed, • Oxygen delivery may be adequate breathing as thickened improved assist patient assume improved upright position and oxygenation of verbalized by mucous ventilation and position to ease work of breathing exercises to tissues and the patient. secretions. adequate breathing. Encourage deep decrease airway collapse, Arterial blood oxygen. slow or pursed lip breathing dyspnea and work of gases (ABGs) • Arterial blood as individually tolerated or breathing. within normal gases (ABGs) indicated. range and free within normal • Routinely monitor skin and • Cyanosis may be peripheral in from symptoms range. mucous membrane color. nail beds or central inlips or of respiratory • No signs of earlobes. Duskiness and distress. respiratory central cyanosis indicate OBJECTIVE: distress. advanced hypoxemia. • Presence of • Encourage expectoration of • Thick, tenacious, copious rhonchi. sputum; suction when secretions are major source • Ineffective LONG TERM: indicated. ineffective airways. Deep cough. After months of suctioning may be required • V/S taken nursing interventions, when cough is ineffective for as the patient: expectoration of secretions. follows: • Ventilation or • Evaluate level of activity • During severe acute T: 37.2 oxygenation tolerance. Provide calm and respiratory distress, patient be P: 79 is adequate to quiet environment. totally unable Perform basic R: 24 meet self care care activities because of BP: 110/80 needs. hypoxemia and dyspnea. • Evaluate sleep patterns, note • Multiple external stimuli and report of difficulties and presence of dyspnea may whether patient feels well prevent relaxation and inhibit rested. sleep. • Monitor vital signs and • Tachycardia, dysrhythmias, cardiac rhythm. changes in blood pressure can effect of systemic hypoxemia on cardiac function. Reference: Carpenito. L .J. (1995). Nursing Diagnosis (6th Ed.), New Jersey J.B.Lippincott Company. Student name: Akbar Ali Arain Discipline B.Sc. N-1(2007-9)