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Assessment Subjective:

Diagnosis

Planning

Intervention

Rationale

Evaluation After 2 days of nursing intervention, the patient displayed time healing of pressure sores.

Impaired skin Within 2  Assessed tissues,  For comparative integrity days of bony prominences, baseline data “naaawa na ko and pressure areas related to nursing sa kapatid ko, physical intervention,  Assessed adequacy  To assess degree of ang dami na nya immobilizatio the patient of blood supply and impairment kasi bed sores innervations of the n as will display eh” as tissue on the sole manifested by timely facilitate verbalized by part of the right foot  To the presence healing of healing.  Promoted optimum the patient’s of pressure pressure nutrition with highbrother sores sores quality protein and without sufficient calories, complicatio vitamins, and ns Objective: mineral Inference  Disruption of skin surface/ presence of wound on lower back  Redness around wounds  Physical immobilizatio n  VS: -abyss wala ako copy ng vs at gcs niya Tsaka pla palagay nalang kung gano na sya katagal sa hosp. Di ko alam eh, sorry physical immobilizatio n

GOAL WAS MET

friction on lower back (sacral part)

supplements promote  Strictly follow the  To circulation and implementation and prevent excessive posting of a turning tissue pressure schedule, restricting 2 hours or less and time in one position to customizing the schedule to patient’s routine.  Practiced aseptic  To reduce the risk for crosstechnique for contamination cleansing/dressing/ medicating lesions  To see changes  Monitored indicative of laboratory values. healing/infection/ complications.

redness on skin

disruption of skin surface

Tissue damage/eru ption of skin

Assessment

Diagnosis Ineffective airway clearance related to retained secretions

Planning Within 2 days of nursing intervention, the patient will demonstrate absence/ reduction of congestion with breath sounds clear, respiration noiseless, improve oxygen exchange

Intervention

Rationale

Evaluation Within 2 days of nursing intervention, the patient demonstrated absence/ reduction of congestion with breath sounds clear, respiration noiseless, improved oxygen exchange as

Subjective:

“ang daming secretions na lumalabas sa bibig at tracheostomy ng kapatid ko.”, as Inference verbalized by physical the patient’s immobilizatio brother.
n

 Assess patient’s  To gain the trust and cooperation condition Monitor and record V/S  Auscultate lung  To know and fields, noting areas determine patient’s needs. To identify of decreased/absent areas of airflow and consolidation and adventitious breath determine possible sounds bronchospasm or obstruction.  Assist patient to  To mobilize change position secretions every 30 minutes  Elevate head of bed  To facilitate and align head in breathing the middle

Objectives:

 Crackles, upon auscultatio inability to n, on both expel lungs secretions  Ineffective / absent cough extensive  Excessive obstruction sputum airway  RR O2 satineffective airway clearance

retained secretions

manifested by:

RR: remove  Suction every 2  To O2 sat: obstructed mucus hours or as necessary  Administer meds as  To reduce ordered. bronchospasm and mobilize secretion Nebulisation of combivent every 8 hours

1. Ineffective Airway Clearance NDx: Ineffective airway clearance related to presence of secretions secondary to pneumonia. The inflammation and increased secretions make it difficult to maintain a patent airway, which is cause by decrease ability to expel the excessive mucus produced that will lead to extensive obstruction of the airway.

Read more at Nurseslabs.com 5 Pneumonia Nursing Care Plans http://nurseslabs.com/pneumonianursing-care-plans/

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