Nursing Care Plan

 


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Medical Diagnosis: Impaired tissue integrity, Ineffective airway clearance, excess mucous, mechanical force of pressure 

Assessment

2

Nursing DX/Clinical Problem

2

Client Goals/Desired Outcomes/Objectives

2

Nursing Interventions/Actions/Orders and Rationale

2

*I

Evaluation

2

Goals

Interventions

Subjective

Patient statements of:

“I don’t change positions very two hours.”

           

“I feel phlegm in my chest but I can’t cough it all up.”

           

Objective

           

Nonblanchable redness on coccyx.

           

Crackles heard in bilateral lower lobes.

Problem

Impaired tissue integrity 

       

Ineffective airway clearance

Long Term:

           

Report any altered sensation or pain at sire of tissue impairment during every assessment until discharge.

           

Patient will maintain a patent airway until discharge.

Monitor the site with every assessment for color changes, redness, swelling, warmth, pain, or other signs of infection. Determine whether the patient is experiencing any changes in sensation or pain.

EBP: Can identify impending problems early (Ackley and Ladwig, pg.  840).

           

Auscultate breath sounds   every 4 hours.

EBP: presence of adventitious breath sounds indicates what is wrong (Ackley and Ladwig, pg. 125.)

           

       

Patient reports no change in pain or sensation with both 0800 and 1200 assessments and agrees to continue to report any changes for the length of stay.

           

O2 saturation at the 1200 assessment was 93%

           

Patient’s airway is patent. No report of difficulty or pain with breathing.

Site monitored with every assessment; no changes have been noted. Oncoming shift will continue monitoring site.

           

           

, oncoming shift will continue to monitor O2 saturation. Crackles still present in lower lobes.

R/T

mechanical force of pressure

       

excess mucous

Short Term:

           

Patient will demonstrate understanding of plan to heal tissue and prevent injury by the end of 1200 assessment on [date].

           

           

Patient will demonstrate effective coughing by the end of 1200 assessment on [date].

           

           

Work with the patient to devise and implement a written treatment plan for topical treatment of the skin impairment site.

EBP: Ensures consistency in care and documentation (Ackley and Ladwig, pg. 840).

Teach the client to turn every two hours and to avoid laying on the site of impaired tissue integrity.

EBP: Used to fully avoid adverse effects of external mechanical forces (Ackley and Ladwig, pg. 841).

           

           

Help patient to cough and deep breathe and perform controlled coughing.

EBP: uses diaphragmatic muscles. Cough is more forceful and effective (Ackley and Ladwig, pg. 125 and 126).

       

Patient seems excited to have a role in determining the treatment of his impaired tissue. At the end of the 1200 assessment, he vocalized that he will change positions every two hours and understand that the nurse on each shift will apply a protective cream to his coccyx every shift.

           

Patient has been coughing and deep breathing every hour but with little mucous production.


Patient admits that he hasn’t been turning every two hours at the end of the 1200 assessment. Additional teaching will be provided to him and amount of turning will be reassessed after the 1600 assessment. Protective cream applied at the end of each skin assessment.

           

           

           

Teaching has been implemented. Assess lung sounds every shift and document any changes.

AEB

nonblanchable redness on coccyx and patient report of not turning every two hours.

       

Ineffective cough and patient report of feeling phlegm in his chest but not being able to get it up by coughing.

       

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Ackley, B.J. and Ladwig, G.B. (2008). Nursing Diagnosis Handbook: An evidence-Based Guide to planning care (8th ed.) St. Louis: Mosby, Elsevier.

*I = Implementation.  Check those interventions/actions/orders that were implemented.



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