ncp for aspiration pnuemonia
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ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE NURSING THEORY EVALUATION Subjective: “Nagapangluya siya kag indi siya mayad kahulag” as verbalize by the folks. Objective: - Lethargy - Verbal reports of weakness - Fatigue - Exhaustio n Activity Intolerance Related to: General weakness and imbalance between oxygen supply and demand. After nursing intervention the patient will demonstrate a measurable increase in tolerance to activity with absence of lethargy and excessive fatigue, and vital signs within client’s acceptable range. Independent: a.) Evaluate client’s response to activity. Note reports of dyspnea, increased weakness / fatigue, an changes in vital signs during and after activities. b.)Provide a quite environmental and limit a.) Establishes patient’s capabilities / needs and facilitates choice of interventions. b.) Reduces stress and excess stimulation, promoting rest. Dorothy Johnson (Human Behavioral System) - This theory focuses on the balance to maintain stability in the system. It also focuses on the behavior of the patient threatened with illness. Also in the medicines that the patient is receiving. Florence Nightingale GOAL PARTIALLY MET After nursing intervention the patient were able to demonstrate measurable increase in tolerance to activity, but not totally. Vital signs within client’s acceptable range.
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Transcript of ncp for aspiration pnuemonia
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE NURSING THEORY
EVALUATION
Subjective:
“Nagapangluya siya kag indi siya mayad kahulag” as verbalize by the folks.
Objective:
- Lethargy- Verbal
reports of weakness
- Fatigue- Exhaustion
Activity Intolerance
Related to:General weakness and imbalance between oxygen supply and demand.
After nursing intervention the patient will demonstrate a measurable increase in tolerance to activity with absence of lethargy and excessive fatigue, and vital signs within client’s acceptable range.
Independent:
a.) Evaluate client’s response to activity. Note reports of dyspnea, increased weakness / fatigue, an changes in vital signs during and after activities.
b.)Provide a quite environmental and limit visitors during acute phase as indicated. Encourage use of stress management and diversional activities as appropriate.
a.) Establishes patient’s capabilities / needs and facilitates choice of interventions.
b.) Reduces stress and excess stimulation, promoting rest.
Dorothy Johnson
(Human Behavioral System)
- This theory focuses on the balance to maintain stability in the system. It also focuses on the behavior of the patient threatened with illness. Also in the medicines that the patient is receiving.
Florence Nightingale
(Environment theory)
- Organizing and manipulating environment (physical, social, and psychosocial) in order to put the person in the best
GOAL PARTIALLY MET
After nursing intervention the patient were able to demonstrate measurable increase in tolerance to activity, but not totally. Vital signs within client’s acceptable range.
c.) Explain importance of rest in treatment plan and necessity for balancing activities with rest.
d.) Assist patient to assume comfortable position for rest / sleep.
g.) Assist with self – care activities as necessary. Provide for progressive
c.) Bed rest is maintained during acute phase to decrease metabolic demands, thus conserving energy for healing. Activity restrictions thereafter are determined by individual client response to activity and resolution of respiratory insufficiency. d.) Patient may be comfortable with the head of bed elevated, sleeping in a chair, or leaning forward on overboard table with pillow support.
g.) Minimizes exhaustion and helps balance
condition alleviate unnecessary pain and suffering.
Dorothy Johnson
(Human Behavioral System)
- This theory focuses on the balance to maintain stability in the system. It also focuses on the behavior of the patient threatened with illness.
Ida Jean Orlando
(Nursing Process – ADPIE)
- Nurses can help the patient what they cannot do to their self.- Exploring the meaning of the need and validating the effectiveness of the action.
Ida Jean Orlando
increase in activities during recovery phase.
oxygen supply and demand. (Nursing Process –
ADPIE)
- Nurses can help the patient what they cannot do to their self.- Exploring the meaning of the need and validating the effectiveness of the action.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE NURSING THEORY EVALUATION
Subjective:
“Gina ubo siya”As verbalized by the folks.
Objective:
- Inability to cough effectively
- Anxiety- Dyspnea- Dry cough
Ineffective Airway Clearance
related to:
-Increased sputum production in response to respiratory infection.
-Decreased energy, fatigue
- After 8 hours of nursing intervention the patient will be able to cough effectively and clear secretions.
- After 8 hours of duty the patient will display patent airway with breath sounds clearing, absence of dyspnea.
Independent:
a.) Monitor Vital signs every hours.
b.) Position patient in a moderated high position or semi fowler’s position.
c.) Turn patient every two hours and PRN.
a.) To asses baseline data of the patient.
b.) To promote maximal lung function.
c.) For repositioning, it promotes drainage of pulmonary secretions and it enhances ventilation to decrease
Dorothy Johnson
(Human Behavioral System)- This theory focuses on the balance to maintain stability in the system. It also focuses on the behavior of the patient threatened with illness.
Ida Jean Orlando
(Nursing Process – ADPIE)
- Nurses can help the patient what they cannot do to their self.
- Exploring the meaning of the need and validating the effectiveness of the action.
GOAL MET
- After the end of the shift, the patient is able to cough effectively and clear secretions.
- After the end of the shift, the patient display patent airway with breath sounds clearing, absence of dyspnea.
d.) Provide oral care.
e.) Instruct patient or the folks regarding medications, side effects, and symptoms of adverse reaction to report to the nurse or physician.
Dependent:a. Administer
medication such as
potential of atelectasis.
d.) Secretions from CAP are often foul tasting and smelling. Providing oral care may decrease nausea and vomiting associated with the taste of secretions.
e.) Promotes prompt identification of potential adverse reaction to facilitate timely intervention.
a.) A variety of
Virginia Henderson
(14 components of Nursing Care)
- Nurses will do what the things that patients cannot do.- From dependence to independence.
Hildegarde Peplau
(Basic care components
- Orientation, Identification, Exploitation & Resolution.
Lydia Hall
(Component of Nursing Care)
antibiotics and expectorants for productive cough.
b. Instruct the patient or the folks to notify nurse if the patient is experiencing shortness of breath or air hunger.
medications are available to treat specific problems.
b.) It may indicate bronchial tubes are blocked with mucus, leading to hypoxia and hypoxemia.
- Care, Core and Cure.- Through medicines the patient can be cured and infection can be cured.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE NURSING THEORY
EVALUATION
Subjective:
“Wala siya mayad nagakaon, wala gana” as verbalize by the folks.
Objective:
Sodium – 136.3
- Starvation- Diabetic acidosis- Dehydration
Height: 152 cm
Weight: 44 kg
BMI: 19.0
Risk for less than body requirements
Related to:
- Increased metabolic needs
- Abdominal distension / gas associated with swallowing air during dyspneic episodes
After nursing intervention the patient will demonstrate a measurable increase in appetite and can tolerate her OTF of 1,500 kilocalories per day / 6 (250 cc of OTF per feeding)
Independent:
a.) Provide covered container for sputum and remove at frequent intervals. Assist with / encourage oral hygiene after emesis, after aerosol and postural drainage treatments, and before meals.
b.) Auscultate bowel sounds. Observe / palpate fro abdominal distention.
c.) Evaluate general nutritional state, obtain baseline
a.) Eliminates noxious sights, tastes, smells from the patient environment and can reduce nausea.
b.) Bowel sounds may be diminished / absent if the infectious process is sever / prolonged. Abdominal distention may occur as a result of air swallowing or reflect the influence of bacterial toxins on the gastrointestinal tract.
c.) Presence of chronic conditions or financial
Virginia Henderson
(14 components of Nursing Care)
- Nurses will do what the things that patients cannot do.
Ida Jean Orlando
(Nursing Process – ADPIE)
- Nurses can help the patient what they cannot do to their self.- Exploring the meaning of the need and validating the effectiveness of the action.
GOAL MET
After nursing intervention the patient were able to demonstrate measurable increase in appetite and can tolerate her feeding.
weight.
limitations can contribute to malnutrition, lowered resistance to infection, and / or delayed response to therapy.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE NURSING THEORY EVALUATION
Subjective:
“Nabudlayan siya mag ginhawa”As verbalized by the folks.
Objective:
- Tachycardia- Restlessness- Dyspnea- Hypoxia
Impaired Gas Exchange
related to:
-Altered oxygen-carrying capacity of blood / release at cellular level
-Altered delivery of oxygen (hypoventilation)
After 8 hours of duty, the patient will improved ventilation and oxygenation of tissues by ABGs within patient’s acceptable range and absence of symptoms of respiratory distress.
Independent:
a.) Observe color of skin, mucous membranes, and nail beds, noting presence of peripheral cyanosis or central cyanosis.
b.) Assess mental status.
a.) Cyanosis of nail beds may represent vasoconstriction or the body’s response to fever / chills; however, cyanosis of earlobes, mucous membranes, and skin around the mouth is indicative of systemic hypoxemia.
b.) Restlessness, irritation, confusion, and somnolence may reflect hypoxemia / decreased cerebral oxygenation.
Hildegarde Peplau
(Basic care components
- Orientation, Identification, Exploitation & Resolution.
GOAL PARTIALLY MET
After 8 hours of duty, the patient was able to improved ventilation and oxygenation of tissues by ABGs within patient’s acceptable range and absence of symptoms of respiratory distress.
pH - 7.45 (7.35 – 7.45)
PCO2 - 41.3 (35 – 45 mmHg)
PO2 - 46.0 (80 – 100 mmHg)
HCO2 - 28.3 (22 – 26 mmol/L)
TCO2 - 66.4
c.) Monitor heart rate / rhythm
d.) Monitor body temperature. Assist with comfort measures to reduce fever and chills.
e.) Maintain bedrest. Encouirage use of relaxation techniques and diversional activities.
f.) Elevate head and encourage frequent position changes,
c.) Tachycardia is usually present as a result of fever / dehydration but may represent a response to hypoxemia.
d.) High fever greatly increases metabolic demands and oxygen consumption and alters cellular oxygenation.
e.) Prevents overexhaustion and reduces oxygen consumption / demands to facilitate resolution of infection.
f.) These measures promotes maximal inspiration, enhance expectorantion of secretions to improve ventilation.
Dorothy Johnson
(Human Behavioral System)- This theory focuses on the balance to maintain stability in the system. It also focuses on the behavior of the patient threatened with illness.
Ida Jean Orlando
(Nursing Process – ADPIE)- Nurses can help the patient what they cannot do to their self.
deep breathing, and ineffective coughing.
Dependent:
a.) Monitor ABGs
a.) Follows progress of disease process and facilities alterations in pulmonary therapy
- Exploring the meaning of the need and validating the effectiveness of the action.
Dorothy Johnson
(Human Behavioral System)- This theory focuses on the balance to maintain stability in the system. It also focuses on the behavior of the patient threatened with illness.
