Scribd Logo
Upload

Welcome to Scribd!

  • 55 views

    Nursing Care Plan: Holy Name University College of Health Sciences Department of Nursing Tagbilaran City, Bohol

    Uploaded by

    Allison Crooke
    The nursing care plan is for a 42-year-old married man named Karl who has been diagnosed with pneumonia. The plan assesses that Karl has ineffective airway clearance related to his pneumonia, as evidenced by shortness of breath. The plan's desired outcomes are for Karl to identify methods to enhance secretion removal, maintain a patent airway, and avoid factors inhibiting clearance within 3 days. Interventions include assessing cough effectiveness, suctioning secretions, encouraging ambulation, using humidified oxygen, administering medications, and assisting with procedures if needed. The evaluation will determine if Karl's airway clearance has improved and he can demonstrate techniques to clear his airway.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Nursing Care Plan: Holy Name University College of Health Sciences Department of Nursing Tagbilaran City, Bohol

    Uploaded by

    Allison Crooke
    55 views4 pages
    The nursing care plan is for a 42-year-old married man named Karl who has been diagnosed with pneumonia. The plan assesses that Karl has ineffective airway clearance related to his pneumonia, as evidenced by shortness of breath. The plan's desired outcomes are for Karl to identify methods to enhance secretion removal, maintain a patent airway, and avoid factors inhibiting clearance within 3 days. Interventions include assessing cough effectiveness, suctioning secretions, encouraging ambulation, using humidified oxygen, administering medications, and assisting with procedures if needed. The evaluation will determine if Karl's airway clearance has improved and he can demonstrate techniques to clear his airway.

    Original Title

    NCP

    Copyright

    © © All Rights Reserved

    Available Formats

    DOCX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    The nursing care plan is for a 42-year-old married man named Karl who has been diagnosed with pneumonia. The plan assesses that Karl has ineffective airway clearance related to his pneumonia, as evidenced by shortness of breath. The plan's desired outcomes are for Karl to identify methods to enhance secretion removal, maintain a patent airway, and avoid factors inhibiting clearance within 3 days. Interventions include assessing cough effectiveness, suctioning secretions, encouraging ambulation, using humidified oxygen, administering medications, and assisting with procedures if needed. The evaluation will determine if Karl's airway clearance has improved and he can demonstrate techniques to clear his airway.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    55 views4 pages

    Nursing Care Plan: Holy Name University College of Health Sciences Department of Nursing Tagbilaran City, Bohol

    Uploaded by

    Allison Crooke
    The nursing care plan is for a 42-year-old married man named Karl who has been diagnosed with pneumonia. The plan assesses that Karl has ineffective airway clearance related to his pneumonia, as evidenced by shortness of breath. The plan's desired outcomes are for Karl to identify methods to enhance secretion removal, maintain a patent airway, and avoid factors inhibiting clearance within 3 days. Interventions include assessing cough effectiveness, suctioning secretions, encouraging ambulation, using humidified oxygen, administering medications, and assisting with procedures if needed. The evaluation will determine if Karl's airway clearance has improved and he can demonstrate techniques to clear his airway.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 4

    HOLY NAME UNIVERSITY

    College of Health Sciences


    Department of Nursing
    Tagbilaran City, Bohol

    NURSING CARE PLAN


    Name of Patient: _Karl___________________________________ Age: ___42_____________________ Status: ______Married________________________________
    Address: ____________________________________________________ Date: ____________________ Ward: __________________________ Bed No: ___________________
    Impression: ______________________________________________________________________________________________________________________________________

    ASSESSMENT/ DIAGNOSIS PLANNING INTERVENTION


    PROBLEM CUES/NRSG. DX RATIONALE OF THE DESIRED BEHAVIORAL NURSING RATIONALE EVALUATION
    PROBLEM OUTCOME(S) OUTCOME(S) INTERVENTIONS
    Subjective cues: Pneumonia can affect After 3 days of After 8 hours of Independent: Goal met:
    Mr. Karl Verbalized people of all ages. The continuous intervention, the The patient was
    shortness of breath infection causes the lungs' intervention the patient will be able - Assess cough - Coughing is the able to identify
    air sacs to become patient will be able to: effectiveness and most effective way to methods to
    inflamed and fill up with to: -demonstrate productivity remove secretions. enhance secretion
    fluid or pus. -identify methods to behaviours to Pneumonia may removal and avoid
    Swelling and mucus can enhance secretion achieve air way cause thick and specific factors that
    make it harder to move air removal clearance tenacious secretions inhibit effective
    through the airways, -identify and avoid -maintain a patent in patients. airway clearance
    making it harder to specific factors that airway with breath then also
    breathe. That can make it inhibit effective sounds clearing. - Suction as indicated: -Stimulates cough or demonstrate a
    hard for the oxygen you airway clearance. frequent coughing, mechanically clears patent airway
    breathe in to get into your adventitious breath airway in a patient clearance.
    bloodstream, this leads to sounds, desaturation who cannot do so
    shortness of breath, related to airway because of ineffective Goal not met:
    difficulty breathing and secretions. cough or decreased
    feeling more tired than level of The patient wasn’t
    normal. consciousness. able to avoid
    - Encourage - Helps mobilize specific factors that
    ambulation. secretions and inhibits effective
    reduces atelectasis. airway clearance
    and not able to
    - Increasing the maintain patent
    humidity will airway clearance.
    - Use humidified decrease the viscosity
    oxygen or humidifier of secretions. Clean
    at the bedside. the humidifier before
    use to avoid bacterial
    growth
    Dependent:
    - Administer - Mucolytics increase
    medications, as or liquefy respiratory
    indicated secretions.,
    expectorants
    - increase productive
    cough to clear the
    airways by liquefying
    lower respiratory
    tract secretions and
    reducing their
    viscosity,
    bronchodilators are
    medications used to
    facilitate respiration
    by dilating the
    airways, and
    analgesics are given
    to improve cough
    effort by reducing
    discomfort but
    should be used
    cautiously because
    they can decrease
    cough effort and
    depress respirations.

    - Assist with - Bronchoscopy is


    bronchoscopy and occasionally needed
    thoracentesis, if to remove mucous
    indicated. plugs, drain purulent
    secretions, and
    obtain lavage
    samples for culture
    and sensitivity and
    thoracentesis is done
    to drain associated
    pleural effusions and
    prevent atelectasis.

    Objective Cues:
    He is anxious because he
    has HIV and pneumonia
    and his wife is cheating on
    him.
    He complains shortness of
    breath, fever and fatigue
    Nursing Diagnosis:
    Ineffective Airway
    Clearance as related to
    pneumonia as evidence by
    shortness of breath.

    You might also like