Care plan carlos Mancia PDF

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Summary

care plan...

Description

Nursing diagnosis

objective/goals

Interventions

Rationale

Evaluation

Short term:

Position the PT in semi Fowler when needed to promote comfort

Upright position limits abdominal contents from pushing upward and inhibiting lung expansion. This position promotes better lung expansion and improved air exchange.

The Patient will show normal breathing sounds and no cough upon discharge from the hospital

Patient: Carlos Mancia Nanda DX: 1. Ineffective airway clearance r/t increased pulmonary secretions evidenced by blood tinged mucous secretions and productive cough 2. Impaired Verbal communica tion r/t language barrier as evidenced by noncomplia nce of mask and isolation precaution s Vital signs

Temp 99.1, BP 124/62, P 77, RR 20, SaO2 91%

Pertinent orders Rule out TB Pertinent assessment Neurological: WNL

Patient will maintain clear, open airways as evidence by normal breath sounds, normal rate and depth of respirations, and ability to effectively cough up secretions after treatments and deep breaths. Patient shows clear understanding of instruction by following airborne precaution protocol and mask compliance

Administer meds as needed (ABX, …) Monitor PTs for change in respiratory status (SOB, O2 level)

Medications are given to manage Provide resources written PT problems in spanish as well Any change in as translator available for the status should be addressed PT continuously quickly to avoid further complications Ensuring a trusting relationship with the PT

The patient will show understanding of tx and Diagnosis by using teach back method and verbal confirmation with the translator after every interaction

Respiratory Pain level

Resources

Hoffman, J. J., & Sullivan, N. J. (2020). Davis advantage for medical-surgical nursing: making connections to practice. Philadelphia: F.A. Davis...