Nursing Care Plan

Assessment Diagnosis
Subjective: Objective: - RR 30 - Use of accessory muscles (nasal flaring) - (+) crackles on both lungs upon auscultati on. - With nasal cannula at 2l/min - Po2 92% - Thick greenish secretions with foul odor. Ineffective airway clearance related to increase production of secretions and increased viscosity.

Planning
After a series of nursing interventions patients Short term goal of 8hrs - Airway secretions will be lessened as evidenced by not using accessory muscles such as nasal flaring. Long term goal of 1week. - Airway secretions will be absent as evidenced by normal RR ranging from 1620, and absence of crackles upon auscultatio n.

Intervention
Independent - Further establish rapport. - Position patient semi fowlers position. - Encourage fluid intake unless contraindicated - Perform chest tapping - Suction patients secretions - Encourage patient to perform deep breathing exercise. - Health teaching (Proper deep breathing exercise, disease process, prevention of complications and control of the disease.) Dependent - 0xygen administration.

Rationale
Independent -To gain trust of patient. -For better lung expansion. -To liquefy secretions. -To loosen secretions. -To lessen secretions. -To facilitate clear airway. Brunner

Evaluation
After a series of nursing intervention patients.. short term goal of 8hours. - Airway secretions were lessen as evidenced by not using of accessory muscles. (Goal met) Long term goal 1 week. - airway secretions was absent as evidenced by lowered RR from 33 to 25, And absence of crackles.

-For management of disease.

Administer prescribed medications. Collaborative - Coordinate with radiologist for chest x-ray - Coordinate with dietician for proper diet. - Collaborate with laboratory for laboratory results. -

Dependent -to improve clinical signs and symptoms, patient comfort and adequate oxygenation. Brunner -to promote better wellness.

Assessment Diagnosi s
Subjective: Objective: - Pitting edema of 3 cm upon palpation. - v/s: BP: 130/90 PR: 64 RR: 30 O2: 92% - Poor skin turgor - Intake: 580 Output: 400 Excess fluid volume r/t water/sodium retention AEB skin indentation of 3 cm upon palpitation

Planning

Intervention

Rationale

Evaluation
After a series of nursing intervention patients.. Short term goal of 8hrs. - Excess fluid as removed by intake of 500 and increased urine output of 720. (Partially Met.) Long term goal - Patient fluid was normalized by absence of pitting edema after I & O and weighing. (Goal Met.)

After series of Independent Independent nursing intervention - Further establish -to gain trust of patient patient. rapport. Short term goal of -to record for any - Record I & O. 8hrs dehydration. -to check if weight - Excess fluid - Weigh daily loss or weight gain. will be save the each removed day - to know extent of AEB - Assess difficult increased areas for edema the edema urine (face, output. foot,legs,hands, Long term goal of arms) -to prevent bed 1week. - Turning of sore and proper - Patients patient every 2 circulation. fluid will be hours. normalized Health teaching -for management of disease. AEB (disease absences process of pitting prevention of edema and complication and normal I & control.) Dependent O Dependent - Prescribe meds - to promote better wellness by physician - To maintain - Restrict or equilibrium on administer fluid patients body as indicated fluids. Collaborative - Collaborate with dietician for proper diets. - Collaborate with laboratory for laboratory results.

Assessment Diagnosis
Subjective: Objective: - (+) blood in stool AEB fecalysis - Hgb 115g/L - Pale skin - Black tarry stool - Weak in appearan ce - Blood type O+ Impaired gastrointestinal tissue perfusion r/t Excess gastric acid manifested by black tarry stool.

Planning
After a series of nursing intervention patient Short term goal of 8hrs. - Patients bleeding will prevented as evidenced by absence of black tarry stool Long term goal of 1 week - Good gastrointesti nal perfusions. As evidenced by (-) blood in stool.

Intervention
Independent - Further establish rapport - Monitor I & O Monitor v/s and possible GI bleeding

Rationale Evaluation
Independent -to gain trust of patient. -to monitor for any dehydration. - To monitor any change in health status of the patients. -for management of disease. After a series of nursing intervention patient Short term goal of 8hrs. - Patient bleeding was lessen as evidenced by stool color consistency. (Goal Partially Met) Long term goal of 1 week - Patient gastrointestin al perfusion was good as evidenced by. (-) blood in stool.

Health Teaching (Disease process, Prevention of complication and control.) Dependent - Monitor meds prescribed by physician Collaborative - Collaborative with lab with laboratory result. - Collaborate with dietician for proper diet. -

Dependent - to promote better wellness