NURSING CARE PLAN
Amanda Aquilini
NURSING DIAGNOSIS:
Ineffective Airway Clearance Related to Viscous Secretions and Shallow Chest Expansion Secondary toDeficient Fluid Volume, Pain, and Fatigue
DESIRED OUTCOMES*/ INDICATORSNURSING INTERVENTIONSRATIONALE
Respiratory Status: Gas exchange[0402], as evidenced by
Absence of pallor and cyanosis(skin and mucous mem-branes)
Use of correctbreathing/coughing techniqueafter instruction
Productive cough
Symmetric chest excursion of at least 4 cmWithin 48–72 hours
Lungs clear to auscultation
Respirations 12–22/min;pulse, 100 beats/min
Inhales normal volume of airon incentive spirometerMonitor respiratory status q4h: rate,depth, effort, skin color, mucousmembranes, amount and color of sputum.Monitor results of blood gases,chest x-ray studies, and incentivespirometer volume as available.Monitor level of consciousness.Auscultate lungs q4h.Vital signs q4h (TPR, BP, pulseoximetry).Instruct in breathing and coughingtechniques. Remind to perform,and assist q3h.Administer prescribed expectorant;schedule for maximum effective-ness. Maintain Fowler’s or semi-Fowler’s position.Administer prescribed analgesics.Notify physician if pain not relieved.To identify progress toward or deviations from goal.
Ineffective Airway Clearance
leads to poor oxygenation, as evidenced bypallor, cyanosis, lethargy, and drowsiness.Inadequate oxygenation causes increased pulse rate. Respira-tory rate may be decreased by narcotic analgesics. Shallowbreathing further compromises oxygenation.To enable client to cough up secretions. May need encour-agement and support because of fatigue and pain.Helps loosen secretions so they can be coughed up and ex-pelled.Gravity allows for fuller lung expansion by decreasing pressureof abdomen on diaphragm.Controls pleuritic pain by blocking pain pathways and alteringperception of pain, enabling client to increase thoracic expan-sion. Unrelieved pain may signal impending complication.
* The NOC # for desired outcomes are listed in brackets following the appropriate outcome. Outcomes, interventions, and activities selected are only a sample of those suggested by NOC and NIC and should be further individualized for each client.
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NURSING CARE PLAN
 Amanda Aquilini
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DESIRED OUTCOMES*/ INDICATORSNURSING INTERVENTIONSRATIONALE
Administer oxygen by nasal cannulaas prescribed. Provide portable oxy-gen if client goes off unit (e.g., for x-ray examination).Assist with postural drainage dailyat 0930.Administer prescribed antibiotic tomaintain constant blood level.Observe for rash and GI or otherside effects.Supplemental oxygen makes more oxygen available to thecells, even though less air is being moved by the client,thereby reducing the work of breathing.Gravity facilitates movement of secretions upward throughthe respiratory passage.Resolves infection by bacteriostatic or bactericidal effect, de-pending on type of antibiotic used. Constant level required toprevent pathogens from multiplying.Allergies to antibiotics are common.
NURSING DIAGNOSIS:
Deficient Fluid Volume: Intake insufficient to replace fluid loss (See standardized care plan forDeficient Fluid Volume, Figure 13-4).
NURSING DIAGNOSIS:
Anxiety related to difficulty breathing and concern about work and parenting roles.
DESIRED OUTCOMES*/ INDICATORSNURSING INTERVENTIONSRATIONALE
Anxiety control [1402], as evi-denced by
Listening to and following in-structions for correct breathingand coughing technique, evenduring periods of dyspnea
Verbalizing understanding of condition, diagnostic tests, andtreatments (by end of day)
Decrease in reports of fear andanxiety
Voice steady, not shaky
Respiratory rate of 12–22/min
Freely expressing concerns andpossible solutions about work and parenting roles Explore al-ternatives as needed.Note whether husband returns asscheduled. If not, institute careplan for actual
Interrupted Family Processes
When client is dyspneic, stay withher; reassure her you will stay.Remain calm; appear confident.Encourage slow, deep breathing.When client is dyspneic, give brief explanations of treatments andprocedures.When acute episode is over, givedetailed information about natureof condition, treatments, and tests.As client can tolerate, encourage toexpress and expand on her con-cerns about her child and her work.Presence of a competent caregiver reduces fear of being un-able to breathe.Control of anxiety will help client to maintain effective breath-ing pattern.Reassures client the nurse can help her.Focusing on breathing may help client feel in control and de-crease anxiety.Anxiety and pain interfere with learning. Knowing what to ex-pect reduces anxiety.Awareness of source of anxiety enables client to gain controlover it. Husband’s continued absence would constitute adefining characteristic for this nursing diagnosis.
 APPLYING CRITICAL THINKING
1.What assumptions does the nurse make when deciding that us-ing a standardized care plan for
Deficient Fluid Volume
is appro-priate for this client?2.Identify an outcome in the care plan and its nursing interventionthat contribute to discharge care planning. What evidence sup-ports your choice?3.Consider how the nurse shares the development of the careplan and outcomes with the client.4.Not every intervention has a time frame or interval specified. Itmay be implied. Under what circumstances is this acceptablepractice?5.In Table 13–1,
Ineffective Airway Clearance
is Amanda’s highestpriority nursing diagnosis. Under what conditions might this diag-nosis be of only moderate priority in Amanda’s case?
See Critical Thinking Possibilities in Appendix A.
* The NOC # for desired outcomes is listed in brackets following the appropriate outcome. Outcomes, interventions, and activities selected are only a sample of those suggested by NOC and NIC and should be further individualized for each client.
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