Prioritized List of Nursing Diagnoses:
| Ineffective airway clearance
| Risk for infection
| Impaired verbal communication
| PLANNING AND IMPLEMENTATION
Data Collection & Organization
| #1 Nursing Diagnosis
| Expected Goal/Outcome
| Nursing Interventions
| Evaluation of Goal/Outcome Attainment
| Subjective:Unobservable subjective data due to patient unresponsive. Objective:- Adventitious lung sounds (rhonchi)- Excessive sputum- History of pneumonia - Presence of Tracheostomy tube- Absent of cough- Respiratory rate of 19 - O2 Sat of 98%- On ventilator machine.Cluster Data:- Was treated for a stage III pressure ulcer that has now healed. - Patient is colonized with Klebsiella in urine.- Has a swelling lesion on palate.
| 1. Ineffective airway clearance related to excessive thick mucous secretions. AEB: The patient’s inability to cough up and remove secretions. Also by the adventitious rhonchi lung sounds present.
| 1. The patient will maintain a patent airway AEB clear lung sounds for 48 hours.
| 1. Assess respiratory rate, depth, rhythm, effort, and breath sounds Q4H and PRN.2a. Suction Q4H and PRN. Note color and consistency of secretion. b. Administrator NEB as ordered. c. Position the HOB at 30 degrees.3.Consult with a Physician about any abnormal laboratory values especially WBC counts.4. Encourage caregivers to repositioned/ turn patient at least Q2H.5. Teach caregivers the significance of changes in sputum (color, character, amount, and odor).
| 1. Changes in respirations, use of accessory muscles, and presence of crackles or wheezes suggest retention of secretions. Airway obstruction can lead to ineffective breathing patterns and impaired gas exchange, resulting in complications, such as pneumonia and respiratory arrest, (Williams).2a. Suctioning removes the mucoid secretions that the patient cannot clear on their own, (Timby...
Please join StudyMode to read the full document