Nursing Care Plan Septic Shock

Topics: Mucus, Skin, Patient Pages: 11 (932 words) Published: May 16, 2013

|ASSESSMENT |DIAGNOSIS |PLANNING |INTERVENTION |RATIONALE |EVALUATION | |Subjective: |Ineffective airway clearance |After 8 hours of therapeutic |Independent: | |After 8 hours of therapeutic | | |r/t retained thick mucous |nursing care, patient’s |Assess airway patency. |Maintaining the airway is always |nursing care, patient’s | |“Ngayon nag bebed bath kami sa |secretions |secretions will be mobilized | |the first priority. |secretions was mobilized and | |kanya at tiniturn naming siya | |and airway will be free from |Auscultate lungs for presence of |These may indicate mucous plug or |airway is free from excessive | |minsan nag susuction din kasi | |excessive secretions, as |adventitious sounds (wheezing, |other major airway obstruction and |secretions, as evidenced by | |may plema.” As verbalized by the| |evidenced by clear lung |coarse crackles). |secretions along larger airways. |clear lung sounds, eupnea, and | |relative of the patient. | |sounds, eupnea, and ability to| |Abnormality indicates respiratory |ability to cough up secretions. | | | |cough up secretions. |Assess respirations; note |compromise. | | |Objective: | | |quality, rhythm, depth, flaring | | | | | | |of nostrils, dyspnea on exertion,| | | |Lying on bed, sleeping, respond | | |use of accessory muscles and | | | |to verbal stimuli in semi fowler| | |position for breathing. | | | |position, with restrain in left | | | | | | |hand with mechanical | | |Assess cough for effectiveness | | | |ventilation, stridor lung sound | | |and productivity. | | | |turn into crackle sound upon | | | |Consider possible causes for | | |auscultation. Ineffective cough.| | | |ineffective cough(respiratory | | |RR is 32cpm. | | | |muscle fatigue, severe | | | | | | |bronchospasm, or thick tenacious |...
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