Tiêu đề nursing process with interventions.pdf ✅

The Nursing process according physiological needs based on Priority 1. Ineffective airway clearance: inability to clear secretions from the respiratory tract or difficulty in maintaining a clear airway Assessment Nursing diagnosis goal intervention Rationale Expected outcome Subjective data Patient complaints of increased cough and inability to bring out the thick mucus secretion, tiredness and lack of sleep at night Objective data - Increased cough/dry cough - Thick secretions - RR-26 B/M - Crackles on auscultation of the right or left lower lung lobe - Spo2:90% - Chest x ray shows pooling of secretions. Ineffective airway clearance related to increased tracheao bronchial secretions The patient will improve and maintain airway clearence  Assess the patient condition  Provide the patient in fowlers  Instruct the patient to take deep breaths exhaling through the mouth before coughing from deep in the lungs  Instruct the patient to take more amount of fluids if not contraindicated  Assist in frequent change of position, lung percussion and vibration  Encourage the patient to do incentive spirometry  Assist in chest physiotherapy  Administer medication as Syrup Benadryl - 5 ml tds Or Syrup Corex – 5 ml tds as per doctors order  Administer nebulizer with bronchodilators such Asthelin or budecord as per doctors order  Administer oxygen if prescribed  Provides baseline data about the patient  Improve the use of diaphragm in breathing  Deep breathing assists in stimulating the cough reflex and mobilizing the retained secretions  Helps to liquefy the secretions and promotes expectorations  This mobilizes the secretions  Helps in lung expansion  As vibration enables loosening of the secretions thereby expectoration  They promote the dilation of the bronchioles and promote airflow.  As they promote dilation of the bronchioles and promote airflow  Prevents hypoxaemia Patient will maintain airway as evidenced by decreased inspiratory and expiratory wheezing, decreased dry and nonproductive cough, RR- 20B/M, normal breath sound,Spo2- 94%.
Assessment Nursing diagnosis goal intervention Rationale Expected outcome Subjective data Patient complaints of drowsiness, lethargy and headache Objective data - Pulse : 88 beats/M - RR: increased - Irritability - Restlessness - Confusion - Decreased Hb - Dyspnea - Nasal flaring - Sweating - SpO2:: 85% Impaired gas exchange related to inadequate oxygenation, Decreased respiratory efforts and retention of carbon di oxide at the alveolar level The patient will have adequate gas exchange  Assess the patient condition  Assist the patient to assume semi fowlers position  Assist with activities of daily living  Allay fear and anxiety and encourage to breathe deeply  Encourage the patient to perform deep breathing and coughing exercises  Promotes the use of incentive spirometry  Demonstrate diaphragmatic and pursed lip breathing  Encourage the patient to quit smoking  Assist with postural drainage by percussion and vibration  Suction to clear the oropharyngeal secretions  Administer oxygen by face mask  Provides base line data about the patient  As it increases the anterio posterior diameter and improve diaphragmatic excursion leading to better lung expansion  This conserves the energy thereby limits the oxygen requirement  As fear and anxiety causes shallow respiratory efforts  As this helps to loosen the secretion  Provides positive feedback on the inspiratory efforts and facilitates lung expansion  Reduces the use of the accessory muscles of respiration and pursed lip breathing creates a positive pressure in the airway  As smoking impairs airway clearance by destroying the cilia, decreases the availability of oxygen, affects the bronchial and alveolar walls, causes vasoconstriction and decreases the pulmonary blood flow  As this loosens the secretions  To remove the secretions  Oxygen as supplementation The patient will maintain adequate gas exchange as evidenced by decreased inspiratory and expiratory wheezing, decreased rhonchi RR:20 breaths/minute Pulse:72 breaths/minute Spo:90% Absence of dyspnea.
 Assist for transfusion of blood or blood products  Encourage intake of iron rich foods raisins, dates, ragi, sprouted pulses, green leafy vegetables.  Administer diuretics as prescribed  Restrict fluid and salt intake as indicated  Assist for Endotracheal intubation and mechanical ventilation if needed increases the oxygen supply to the tissues  To gradually increase the hemoglobin levels  To gradually increase the hemoglobin levels  To relieve pulmonary congestion  To prevent fluid retention  To maintain patent airway and oxygenation to tissues.
3. Ineffective breathing pattern: inadequate ventilation-either inspiration or expiration Assessment Nursing diagnosis goal intervention Rationale Expected outcome Subjective data Patient verbalizes difficulty in breathing Objective data - Dyspnoeic - Presence of shortness of breath - Tachypnoeic - Anxious - Use of accessory muscles for breathing - Shallow respiration - Irregular breathing - Rhythm nasal flaring - Decreased Spo2 Ineffective breathing pattern related to pain/anxiety /impaired neuro muscular/ impaired musculoske letal/ decreased energy Patient will maintain effective breathing pattern  Assess the patients breathing pattern  Place the patient in semi fowlers position  Provide additional pillows to maintain semi fowlers position  Change the position of the patient every 2nd hourly  Teach deep breathing exercises and ask the patient to do every 1-2 hrs  Splint the chest or abdominal incision if any, with pillow during coughing  Implement measures to reduce anxiety if present  Encourage the patient to use incentive spirometry every 2 hours  Provide rest periods between activities  Notify the physician if ineffective breathing pattern continues  Administer oxygen as prescribed  Provides baseline data about the patient  Allows maximum lung expansion  To prevent pushing up of abdominal content  To promote maximum lung expansion  Deep breathing results in maximum inhalation and lung expansion  Deep breathing exercises to prevent strain at the incisional site and to promote deep breathing  Reducing shallow breathing and promoting deep breathing  To promote maximum lung expansion  To conserve energy  To modify the treatment regimen  To prevent hypoxemia and promote tissue oxygenation. Patient will maintain an effective breathing pattern as evidenced by verbalizatio n of comfortable breathing. Assessment reveals normal breathing rate and rhythm RR:26 B/M Spo2:90%
4. Impaired oral mucous membrane: The state in which an individual experiences or is at risk or disruption of oral cavity Assessment Nursing diagnosis goal intervention Rationale Expected outcome Subjective data Patient verbalizes that he/she has pain in the mouth, taste change Objective data -coated tongue - Dry mouth - Presence of secretions - Lesions - Exudates or dryness - Nil per oral - Presence of Endotracheal tube - Bad odour Impaired mucous membrane related to inflammation/ NPO/ Drug effects/ infection /trauma / decreased salivation Maintains normal integrity of oral mucus membrane  Assess the patient condition  Maintain good oral hygiene  Apply glycerine or liquid paraffin over lips after each mouth care  Avoid mouthwashes that contain alcohol  Avoid spicy, hot food, alcohol, hard foods  Give normal saline mouth gargles when the patient has ulcers  Apply xylocaine viscous before feeding  Educate the patient and family members on the importance of oral hygiene and fluid intake  Fit the dentures correctly and firmly  Use soft bristle tooth brushes  Provides base line data about the patient  In order to prevent ulceration and dryness  To prevent dryness  As it causes dryness resulting in further irritation  To avoid bleeding  Helps to avoid bleeding while brushing  If the ulcer is too extensive  Helps to maintain oral hygine  Ill fitting dentures causes ulcers over gums  Avoid bleeding and injury to soft oral mucosa The patient will maintain intact oral mucosa as evidenced by moist, well hydrated tongue and lips, absence of halitosis