Nursing Care Plan


Return to Care Plan Listing
 






Medical Diagnoses: Ineffective airway clearance related to mucus in the lungs, impaired gas exchange, ineffective breathing pattern and Nausea.


1.  Ineffective airway clearance related to mucus in lungs.

 

:  Coughing sputum.

 

:  Patient has difficulty breathing.

 

:  Wheezing upon admission.

2.  Impaired gas exchange related to lung infection. 

 

:  Patient has dyspnea.

 

:  Patient restless and anxious upon admission.

 

:  Patient lethargic and difficult breathing.

3.  Ineffective breathing pattern related to lung infection.

 

:  Patient has difficulty breathing.

 

:  Patient has pain when breathing.

 

:  Patient has fatigue.

4.  Nausea related to antibiotics.

 

:  Patient vomiting due to excessive antibiotics.

 

:  Patient states nausea and pain.

 

:  Patient gagging and excessive

38 AA   Female   Full Code

BP 107/61       Temp 98.1 F

HR 92    RR 16  Clear Lung Sounds

O2 sats 97 on room air

Height 167.64 cm  Weight 93.80 kg

Allergy:  Egg, Gluten, Ibuprofen, Morphine

½ pack a day smoker for 17 years.

 

Chief Complaint:  Difficulty breathing and painful breathing.  No energy, chills, pain and does not feel right. 

5.  Sleep deprivation related to illness and hospital environment.

 

:  Patient states difficulty sleeping due to breathing difficulty.

 

:  Patient states very uncomfortable in the hospital and finds it noisy.

6.  Ineffective health maintenance related to acquiring post op lung infection.

 

:  Patient failed to cough/deep breathe post op from 2/22/12 surgery.

 

:  Patient did not use IS post op.

:  Patient continued to smoke.

8.  Risk for aspiration related to excess secretions in lungs.

 

:  Recent neck surgery; sedation.

 

:  Acute Lung infection.

7.  Deficient knowledge related to lung function.

 

:  Patient is ½ pack a day smoker, 17 yrs.

 

:  Patient would not cough/deep breathe after surgery. 


NANDA Diagnostic Statement: Ineffective airway clearance related to increased mucus in the lungs as evidenced by patient states difficult and painful breathing. 

Behavioral Outcome / Goal: To maintain airway patency and to have a reduction of congestion, clear breath sounds and O2 sats > 95 on room air within 48 hours or upon discharge.      

 

References:  Potter & Perry; Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales; Brunner & Suddarth’s Textbook of Medical-Surgical Nursing.


Nursing Interventions:

 

1.  Cough and Deep Breathing

 

2.  Administer prescribed medications

 

3.  Breathing treatments

 

4.  Incentive Spirometer

 

5.  Ambulation as much as tolerated.

 

6.  Educate patient about the importance of smoking cessation.

7.  Position in a semi fowlers.

 

8.  Encourage fluids.

Rationale:

 

1.  Helps to keep lungs clear.

2.  Antibiotics required to treat pneumonia.

 

3.  Dilates bronchial tubes to help breathing.

 

4.  Helps to keep lungs clear and improve lung function.

 

5.  Ambulation is going to help keep lungs clear and free of excess fluid.

 

6.  Smoking greatly increases the risk for pneumonia and other lung illness.

 

7.  Semi fowler more comfortable position for breathing difficulties.

 

8.  Fluids help to thin mucus and secretions which make it easier to expel

Client Response:

1.  Not making productive cough.  Educated on importance of deep breath/cough.

2.  Client takes all meds.  Did end up with excessive level of Vancomycin. 

 

3.  Responding well to treatment and feels relief.

 

4.  Not faithful about using IS.  Educated patient on importance of using as ordered.

 

5.  Client is getting up and voiding on her own and moves to chair periodically. 

 

6.  Client smoke free since admission and states that she will remain smoke free.

 

7.  States this position is more comfortable.

 

8.  Patient is doing very well with fluid intake.

Summarize impressions of client progress toward outcomes / problem resolution: Patient is stable and now that Vancomycin has decreased is free of nausea and stomach pain.  (3/1/12 had level of 32.6)  She has been educated on the importance of deep breathing and coughing, the use of IS which is crucial for her, and the need for her to stop smoking.  She has been smoke free since admission and says that she knows she must quit and feels that she can at this time.  She has good family support and husband states he wants her to be smoke free and will help her with this goal.  He will also remind and encourage her to use her IS and to keep moving. 


Return to Table of Contents