Nursingcrib.com Nursing Care Plan - Bronchitis
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Transcript of Nursingcrib.com Nursing Care Plan - Bronchitis
STUDENT NURSES’ COMMUNTY NURSING CARE PLAN - Bronchitis
ASSESSMENT DIAGNOSIS OBJECTIVE INTERVENTION RATIONA LE EVALUATION
Subjective: “ Nahihirapan ako huminga” (Im having difficulty breathing) as verbalized by the patient. Objective: • Presence of
rhonchi. • Ineffective
cough. • V/S taken as
follows:
T: 37.2 P: 79 R: 24 BP: 110/80
Ineffective airway clearance related to excessive, thickened mucous secretions.
Short term: After 8 hours of nursing interventions the patient will: • Demonstrate
improved ventilation and adequate oxygen.
• Arterial blood
gases (ABGs) within normal range.
• No signs of
respiratory distress.
Long term: After months of nursing interventions, the patient: • Ventilation or
oxygenation is adequate to meet self care needs.
Independent: • Assess respiratory
rate, depth. Note use of accessory muscles, pursed lip breathing, Inability to speak.
• Elevate head of the
bed, assist patient assume position to ease work of breathing. Encourage deep slow or pursed lip breathing as individually tolerated or indicated.
• Routinely monitor skin
and mucous membrane color.
• Encourage
expectoration of sputum; suction when indicated.
• Useful in evaluating
the degree or respiratory distress and chronicity of the disease process.
• Oxygen delivery
may be improved by upright position and breathing exercises to decrease airway collapse, dyspnea and work of breathing.
• Cyanosis may be
peripheral in nail beds or central in lips or earlobes. Duskiness and central cyanosis indicate advanced hypoxemia.
• Thick, tenacious,
copious secretions are major source if ineffective airways. Deep suctioning may be required when cough is ineffective for expectoration of secretions.
• Patient display
improved ventilation and adequate oxygenation of tissues and Arterial blood gases (ABGs) within normal range and free from symptoms of respiratory distress.
STUDENT NURSES’ COMMUNTY
• Evaluate level of activity tolerance. Provide calm and quiet environment.
• Evaluate sleep
patterns, note report of difficulties and whether patient feels well rested.
♦ Monitor vital signs and
cardiac rhythm. Collaborative: • Administer
supplemental oxygen as indicated by ABG results and patients tolerance.
• During severe or acute respiratory distress, patient may be totally unable to perform basic self care activities because of hypoxemia and dyspnea.
• Multiple external
stimuli and presence of dyspnea may prevent relaxation and inhibit sleep.
• Tachycardia,
dysrhythmias, and changes in blood pressure can reflect effect of systemic hypoxemia on cardiac function.
• May correct or
prevent worsening of hypoxia.