Nursing care plans

it includes the nursing care plan examples related to the respiratory system and their intervention in ideal format. check this for your reference. it help us to know the planning. its given according to NANDA nursing diagnosis.

1. NURSING CARE PLAN

2. EXAMPLE OF RESPIRATORY SYSTEM

3. NURSING ASSESSMENT Note changes suggesting increased work of breathing ( tachypnea , diaphoresis, intercostal muscle retraction, fatigue) or pulmonary edema (fine, coarse crackles or rales , frothy pink sputum). Assess breath sounds. Diminished or absent sounds indicate inability to ventilate the lungs sufficiently to prevent atelectasis . Crackles indicate ineffective airway clearance, fluid in the lungs

4. Conti.. Wheezing indicates narrowed airways and bronchospasm . Rhonchi and crackles indicate ineffective secretion clearance. Assess level of consciousness (LOC) and ability to tolerate increased work of breathing. Confusion, rapid shallow breathing, abdominal paradox (inward movement of abdominal wall during inspiration), and intercostal retractions suggest inability to maintain adequate minute ventilation. Assess for signs of hypoxemia and hypercapnia

5. Determine vital capacity (VC), respiratory rate, and negative inspiratory force (NIF) and compare with values indicating need for mechanical ventilation: VC < 10 to 15 mL /kg. Respiratory rate > 35 breaths/minute. NIF <15 to 25 cm H 2 O. Analyze ABG and compare with previous values. If the patient cannot maintain a minute ventilation sufficient to prevent CO 2 retention, pH will fall. Mechanical ventilation or noninvasive ventilation may be needed if pH falls to 7.30 or below.

6. Conti.. Determine hemodynamic status (blood pressure, pulmonary wedge pressure, cardiac output, Svo 2 ) and compare with previous values. If patient is on mechanical ventilation and positive end-expiratory pressure (PEEP), venous return may be limited, resulting in decreased cardiac output.

7. Nursing Diagnoses Impaired Gas Exchange related to inadequate respiratory center activity or chest wall movement, airway obstruction, and/or fluid in lungs Ineffective Airway Clearance related to increased or tenacious secretions Ineffective Airway Clearance related to sputum production

8. Conti.. Acute Pain related to inflammatory process and dyspnea Risk for Injury secondary to complications Ineffective Tissue Perfusion (Pulmonary) related to decreased blood circulation Anxiety related to dyspnea , pain, and seriousness of condition Risk for Injury related to altered hemodynamic factors and anticoagulant therapy

9. Nursing Diagnosis Ineffective Breathing Pattern related to pulmonary infection and potential for long-term scarring with decreased lung capacity Risk for Infection related to nature of the disease and patient's symptoms Imbalanced Nutrition: Less Than Body Requirements related to poor appetite, fatigue, and productive cough Noncompliance related to lack of motivation and long-term treatment

10. ASSESSMENT NURSING DIAGNOSIS GOAL / EXPECTED OUTCOME INTERVENTION / PLANNING IMPLEMENTATION RATIONAL EVALUATION Subjective data - Impaired gas exchange related to inadequate respiratory center activity or chest wall movement, airway obstruction, and/or fluid in lungs Improving gas exchange Assess general condition of patient Assessment is done To know the baseline data and for patients cooperation Respiratory rate and ABG values within patient's are at normal limits Administer antibiotics, cardiac medications, and diuretics as ordered for underlying disorder. Medication given To improve the condition of patient Administer oxygen Oxygen therapy provided To maintained oxygen saturation in the body

11. ASSESSMENT NURSING DIAGNOSIS GOAL / EXPECTED OUTCOME INTERVENTION / PLANNING IMPLEMENTATION RATIONAL EVALUATION OBJECTIVE DATA= Impaired gas exchange related to inadequate respiratory center activity or chest wall movement, airway obstruction, and/or fluid in lungs Improving gas exchange Monitor fluid balance by intake and output measurement Intake and output charts maintained To detect presence of hypovolemia or hypervolemia Respiratory rate and ABG values within patient's are at normal limits Monitor adequacy of alveolar ventilation by frequent measurement of respiratory rate, VC, inspiratory force, and ABG levels. Vital signs taken To know the lungs functions. Give comfortable position Fowlers position given To breath properly and feel comfort Checked oxygen saturation of patient Saturation maintained To know the oxygen level of the body

12. ASSESSMENT NURSING DIAGNOSIS GOAL / EXPECTED OUTCOME INTERVENTION / PLANNING IMPLEMENTATION RATIONAL EVALUATION Subjective data - Ineffective airway clearance related to increased or tenacious secretions Maintaining airway clearance Assess general condition of patient Assessment is done To know the baseline data and for patients cooperation Decreased secretions; lungs clear Administer medications to increase alveolar ventilation that is bronchodilators and corticosteroids Medication is given Bronchodilators to reduce bronchospasm , corticosteroids to reduce airway inflammation. Checked vitals of patient Vitals are taken To know the vital statistics Perform chest physiotherapy Physiotherapy is performed To remove mucus

13. ASSESSMENT NURSING DIAGNOSIS GOAL / EXPECTED OUTCOME INTERVENTION / PLANNING IMPLEMENTATION RATIONAL EVALUATION Objective data - Ineffective airway clearance related to increased or tenacious secretions Maintaining airway clearance Teach slow, pursed-lip breathing Breathing exercises taught To reduce airway obstruction. Decreased secretions; lungs clear Administer I.V. Fluids and mucolytics Administered To reduce sputum viscosity. Suction patient as needed To assist with removal of secretions. Administer steam inhalation Steam is given To clear the airway and decrease the secretions

14. ASSESSMENT NURSING DIAGNOSIS GOAL / EXPECTED OUTCOME INTERVENTION / PLANNING IMPLEMENTATION RATIONAL EVALUATION Subjective data - Ineffective Airway Clearance related to sputum production Establishing Effective Airway Clearance Assess general condition of patient Assessment is done To know the baseline data and for patients cooperation Coughs up clear secretions effectively Administer medications to increase alveolar ventilation that is bronchodilators and corticosteroids Medication is given Bronchodilators to reduce bronchospasm , corticosteroids to reduce airway inflammation. Checked vitals of patient Vitals are taken To know the vital statistics Objective data - Perform chest physiotherapy Physiotherapy is performed To remove mucus

15. ASSESSMENT NURSING DIAGNOSIS GOAL / EXPECTED OUTCOME INTERVENTION / PLANNING IMPLEMENTATION RATIONAL EVALUATION Subjective data - Ineffective Airway Clearance related to sputum production Establishing Effective Airway Clearance Teach slow, pursed-lip breathing Breathing exercises taught To reduce airway obstruction. Coughs up clear secretions effectively Give steam inhalation and nebulization to patient Steam and nebulization is given To expell out the secreations Clear the airway by doing suction Suctioning is done To clear the airway Objective data -

16. ASSESSMENT NURSING DIAGNOSIS GOAL / EXPECTED OUTCOME INTERVENTION / PLANNING IMPLEMENTATION RATIONAL EVALUATION Subjective data - Acute Pain related to inflammatory process and dyspnea Relieving Pleuritic Pain Assess general condition of patient Assessment is done To know the baseline data and for patients cooperation Appears more comfortable; free of pain Place in a comfortable position (semi-Fowler's) for resting and breathing Semifowlers position given To improve breathing encourage frequent change of position Changed position every two hourly to prevent pooling of secretions in lungs. Objective data - Demonstrate how to splint the chest while coughing Supported to chest while coughing To feel comfort

17. ASSESSMENT NURSING DIAGNOSIS GOAL / EXPECTED OUTCOME INTERVENTION / PLANNING IMPLEMENTATION RATIONAL EVALUATION Subjective data - Acute Pain related to inflammatory process and dyspnea Relieving Pleuritic Pain Administer prescribed analgesic Analgesics given To reduce pain level Appears more comfortable; free of pain Objective data - Apply heat and/or cold to chest as prescribed. Heat compression is applied To reduce pain Administer oxygenation Oxygen provided To reduce dyspnea

18. ASSESSMENT NURSING DIAGNOSIS GOAL / EXPECTED OUTCOME INTERVENTION / PLANNING IMPLEMENTATION RATIONAL EVALUATION Subjective data - Risk for Injury secondary to complications Monitoring for Complications Assess general condition of patient Assessment is done To know the baseline data and for patients cooperation Fever controlled, no signs of resistant infection Monitor vital signs Vital signs are monitored to assess the patient's response to therapy. Auscultate lungs and heart Lungs and heart is ascultate Heart murmurs or friction rub may indicate acute bacterial endocarditis , pericarditis , or myocarditis Objective data - Maintain intake and output Intake and output is maintained To feel comfort

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