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NCP Er (Day2)

The nursing care plan is for a 48-year-old female patient with difficulty breathing due to retained secretions in the bronchi from pneumonia. The plan involves monitoring vital signs every 4 hours, listening to breath sounds for crackles or wheezes, positioning the patient with elevated head, encouraging deep breathing and coughing exercises, and administering nebulized salbutamol and antibiotics as ordered to clear the secretions and treat the infection. After 1 hour the interventions were successful as the patient was able to expectorate secretions and breathe normally without crackles or wheezes.

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Raiel B. Buenviaje RN
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92 views2 pages

NCP Er (Day2)

The nursing care plan is for a 48-year-old female patient with difficulty breathing due to retained secretions in the bronchi from pneumonia. The plan involves monitoring vital signs every 4 hours, listening to breath sounds for crackles or wheezes, positioning the patient with elevated head, encouraging deep breathing and coughing exercises, and administering nebulized salbutamol and antibiotics as ordered to clear the secretions and treat the infection. After 1 hour the interventions were successful as the patient was able to expectorate secretions and breathe normally without crackles or wheezes.

Uploaded by

Raiel B. Buenviaje RN
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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NURSING CARE PLAN Patients Initials: B.

S Age: 48 y/o Sex: Female Cues/ Needs Subjective data: Medyo nahihirapan pa din ako huminga marama pa kasi yatang plema, as verbalized by the client. Objective data: -Vital signs: BP: 130/90 mmHg PR: 87 bpm RR: 25 bpm T: 36.7C -(+) crackles on both lungs -(+) use of accessory muscles -difficulty of breathing -wheezes heard upon auscultation -nonproductive cough -with nasal cannula of 1-2 LPM Nursing Diagnosis Ineffective airway clearance related to retained secretions in bronchi secondary to pneumonia. Rationale Ineffective airway clearance caused by inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway. Goal and Objectives After 1 hour of nursing intervention, patient will be able to expectorate secretions that patient can breathe normally as evidenced by: - Absence of crackles on both lungs - Absence of wheezes upon auscultation - RR of 12-20 bpm Interventions 1. Monitoring of vital signs q4 hrs 2. Auscultate breath sounds, note adventitious sounds Rationale 1. to have baseline data 2. some degree of bronchospasm is present with obstruction in airway and may/ may not be manifested in adventitious breathe sounds Evaluation After 1 hour of nursing intervention, the goal was met. The patient was able to expectorate secretions that patient can breathe normally as evidenced by: - Absence of crackles on both lungs - Absence of wheezes upon auscultation - RR of 12-20 bpm

3. Assist client into 3. elevation of the high-fowlers head of the bed position. facilitates respiratory function by use of gravity 4. Encourage deep breathing and coughing exercises 4. facilitates maximum expansion of the lungs and small airways 5. to prevent pneumonia and promote good circulation

Reference: Nurses Pocket Guide ed. 11 (pp. 77-81)

5. Turning the patient every 2 hours

Labs: -with O2 saturation of 96% -chest x-ray -C/S results of sputum (+) for pneumocystis jiroveci

6. Do back tapping 7. Give salbutamol nebulization as ordered by the physician 8. Administer antibiotics (e.g cotrimoxazole) as ordered by the physician 9. Discuss with the physician the need to increase fluid intake and carry our if ordered

6. to loosen the secretions 7. facilitates liquefaction and removal of secretions 8. to decrease the virulence and kill the virus

9. increase fluid intake rehydrates the body in that way, the mucus produced will be thin in consistency and will be easier to suction or cough out.

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