STUDENT NURSES’ COMMUNTY NURSING CARE PLAN - Bronchitis

ASSESSMENT DIAGNOSIS OBJECTIVE INTERVENTION RATIONA LE EVALUATION

Subjective: “ Nahihirapan ako huminga” (Im having difficulty breathing) as verbalized by the patient. Objective: • Presence of

rhonchi. • Ineffective

cough. • V/S taken as

follows:

T: 37.2 P: 79 R: 24 BP: 110/80

Ineffective airway clearance related to excessive, thickened mucous secretions.

Short term: After 8 hours of nursing interventions the patient will: • Demonstrate

improved ventilation and adequate oxygen.

• Arterial blood

gases (ABGs) within normal range.

• No signs of

respiratory distress.

Long term: After months of nursing interventions, the patient: • Ventilation or

oxygenation is adequate to meet self care needs.

Independent: • Assess respiratory

rate, depth. Note use of accessory muscles, pursed lip breathing, Inability to speak.

• Elevate head of the

bed, assist patient assume position to ease work of breathing. Encourage deep slow or pursed lip breathing as individually tolerated or indicated.

• Routinely monitor skin

and mucous membrane color.

• Encourage

expectoration of sputum; suction when indicated.

• Useful in evaluating

the degree or respiratory distress and chronicity of the disease process.

• Oxygen delivery

may be improved by upright position and breathing exercises to decrease airway collapse, dyspnea and work of breathing.

• Cyanosis may be

peripheral in nail beds or central in lips or earlobes. Duskiness and central cyanosis indicate advanced hypoxemia.

• Thick, tenacious,

copious secretions are major source if ineffective airways. Deep suctioning may be required when cough is ineffective for expectoration of secretions.

• Patient display

improved ventilation and adequate oxygenation of tissues and Arterial blood gases (ABGs) within normal range and free from symptoms of respiratory distress.

STUDENT NURSES’ COMMUNTY

• Evaluate level of activity tolerance. Provide calm and quiet environment.

• Evaluate sleep

patterns, note report of difficulties and whether patient feels well rested.

♦ Monitor vital signs and

cardiac rhythm. Collaborative: • Administer

supplemental oxygen as indicated by ABG results and patients tolerance.

• During severe or acute respiratory distress, patient may be totally unable to perform basic self care activities because of hypoxemia and dyspnea.

• Multiple external

stimuli and presence of dyspnea may prevent relaxation and inhibit sleep.

• Tachycardia,

dysrhythmias, and changes in blood pressure can reflect effect of systemic hypoxemia on cardiac function.

• May correct or

prevent worsening of hypoxia.