URTI-NCP - Nursing care plan on upper respiratory tract infections PDF

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Nursing care plan on upper respiratory tract infections...

Description

ASSESSMENT

NURSING DIAGNOSIS

SUBJECTIVE DATA: “nahihirapan ako huminga, para akong hinahapo.”

Ineffective Airway Clearance related to Impaired respiratory muscle function as evidenced by Abnormal respiratory rate, rhythm, and depth

OBECTIVE DATA  Use of accessory muscle when breathing  Dyspnea V/S taken as follows: T: 36.5 RR: 14 PR: 75 BP: 110/70

PLANNING After 3 hours of nursing diagnosis, the 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.  Demonstrate increased air exchange. After a series of nursing intervention, the patient will;  Identify and avoid specific factors that inhibit effective airway clearance. LONG TERM GOAL: To facilitate the maintenance of a supply of oxygen to all body cells

INTERVENTION 1. Assess airway for patency. 2. Teach the patient the proper ways of coughing and breathing 3. Position the patient upright if tolerated. Regularly check the patient’s position to prevent sliding down in bed. 4. Maintain humidified oxygen as prescribed. 5. Encourage patient to increase fluid intake to 3 liters per day within the limits of cardiac reserve and renal function. 6. Coordinate with a respiratory therapist for chest physiotherapy and nebulizer management as indicated. 7. Educate patient on coughing, deep breathing, and splinting techniques.

RATIONALE 1. Maintaining patent airway is always the first priority, especially in cases like trauma, acute neurological decompensation, or cardiac arrest. 2. The most convenient way to remove most secretions is coughing. So it is necessary to assist the patient during this activity. Deep breathing, on the other hand, promotes oxygenation before controlled coughing. 3. Upright position limits abdominal contents from pushing upward and inhibiting lung expansion. This position promotes better lung expansion and improved air exchange. 4. Increasing humidity of inspired air will reduce thickness of secretions and aid their removal. 5. Fluids help minimize mucosal drying and maximize ciliary action to move secretions. 6. Chest physiotherapy includes the techniques of postural drainage and chest percussion to mobilize secretions from smaller airways that cannot be eliminated by means of coughing or suctioning. 7. Patient will understand the underlying principle and proper techniques to keep the airway clear of secretions.

EVALUATION THE GOAL HAS BEEN MET. After 3 hours of nursing diagnosis, the patient was able to;  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.  Demonstrated increased air exchange. After a series of nursing intervention, the patient will;  Identify and avoid specific factors that inhibit effective airway clearance. LONG TERM GOAL: Facilitated the maintenance of a supply of oxygen to all body cells...