Nursing Care Plan
Problem: Impaired Ventilation
| Assessment |Nursing Diagnosis |Planning |Intervention |Rationale |Evaluation | |Subjective: |Impaired spontaneous ventilation |Within 8hrs of nursing |Independent: | | | |“Gi ubo/sipon siya before na |related to accumulation of upper |interventions the pt won’t | | |After 8hrs of nursing | |disgrasya. Pagka disgrasya naka inum |airways secretions secondary to VA|exhibit signs of respiratory |Assess pt’s condition |To know and determine pt’s need |interventions the pt’s | |siya ug mga dugo niya mao nang | |distress or infection | | |temperature has risen to | |gibutangan siya ana (tracheostomy) | | | |To establish baseline data –Temp. |38.0C but isn’t showing | |para ma suyop to ky mag lisud man | | |Assess and monitor client’s temperature. |above 37.5ᴼC may suggest acute |signs of respiratory | |siya ginhawa..” As verbalized by the | | | |infectious disease process. |distress | |mother. | | | | | | | | | | |To facilitate breathing |Goal Partially Met | |Objective: | | |Elevate head of bed and align head in the middle | | | |Increased use of accessory muscles | | | | | | | | | |Raise side rails |For safety measures | | |Irritable | | | | | | | | | |Provide TSB |Water applied to skin causes the pores| | |Restlessness | | | |to open allowing excess heat to | | | | | | |escape. Evaporation creates cooling | | |Creatinine and SGPT(ALT) Result: | |...
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