NCP 1 Actual measles - jgbjg PDF

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ASSESSMENT Subj e c t i v eDa t a: Ob j e c t i v eDa t a:

Vi t a lSi g ns : BP - 100/70 RR - 25 T - 38.3 HR - 116 O2 saturation 95%

NURSI NG BACKGROUND DI AGNOSI S KNOWLEDGE I n e ffe c t i v e Pr od u c t i v ec ou g h a i r wa y c l e a r a nc e r e l a t e dt o Ba c t e r i a l i n c r e a s e d c ol o ni s a t i o n p r od u c t i o nof s e c r e t i o nsa s Ne ut r o ph i l i c e vi d e nc e db y i n fla mma t i o n p r od u c t i v e c ou g h

GOALSOF CARE Wi t h i n1h ou ro f n ur s i n g i n t e r v e nt i o n, t he p a t i e n twi l lb e a b l et o: -Ex pe c t o r a t e s e c r e t i on sa n d ma i nt a i n p a t e n ta i r wa y c l e a r a nc e .

Ai r wa ye p i t he l i a l b l oc ka g e -De mo ns t r a t e p r op e r c o u g hi n ga nd I mpa i r e d b r e a t hi n g muc o c i l i a r y c l e a r a nc e -I nd i c a t e v e r b a l l yor t h r ou g h I n e ffe c t i v ea i r wa y b e h a vi o r , c l e a r a nc e f e e l i n gof c o mf o r t a b i l i t ywh e n b r e a t hi n g .

I NTERVENTI ON

RATI ONALE .

EVALUATI ON Af t e r1ho uro f n ur s i n g i n t e r v e nt i o n, t h e p a t i e n twa sa bl e t o : -Exp e c t or a t e d s e c r e t i o nsa n d ma i n t a i n p a t e n ta i r wa y c l e a r a nc e . -De mo ns t r a t e d p r op e r c ou g hi n ga n d b r e a t h i n g

-I n di c a t e d v e r b a l l yor t h r ou g h b e h a vi o r , f e e l i n gof c omf or t a b i l i t y wh e n b r e a t h i n g . Go a lme t

Ca u s e so fc h r o ni cp r od uc t i v ec o u g h:Ana pp r oa c ht oma n a g e me nt . ( 20 15 ,Se p t e mbe r1 ) .Sc i e n c e Di r e c t . h t t ps : / / www. s c i e nc e d i r e c t . c o m/ s c i e n c e / a r t i c l e / pi i / S09 54 61 11 15 3 00 01 9...