ncp

IV. NURSING CARE PLAN

ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

1. dyspnea
2. coughing
3. cyanosis
4. tachypnea
Ineffective breathing pattern related to increased work of breathing.
At the end of 8 hours of duty, the patient will be able to know how to deal with the situation and lessen the respiratory distress being experienced.
Assess respiratory status when the patient is calm. A minimum of every 2-4 hours or more often as indicated for an increasing or decreasing respiratory rate and episodes of apnea.











Administer humidified oxygen via mask, nasal cannula, hood, or tent


Assess pulse oximetry on room air and compare to reading when child is on oxygen.

Note patient’s response to ordered medications.



Position head of the bed up or place child in position of comfort.
Changes in breathing pattern may occur quickly as the patient’s energy reserves are depleted. Assessment and monitoring baseline reveal rate and quality of air exchange. Frequent assessment and monitoring provides objective evidence of changes in the quality of respiratory effort, enabling prompt and effective intervention.


Humidified oxygen loosens secretions, helps maintain oxygenation status and eases respiratory distress.

Comparison of pulse oximetry readings provides information about improvement status.

Medications act systematically to improve oxygenation and decrease inflammation.

Position facilitates improved aeration and promotes decrease in anxiety and energy expenditures.
At the end of 8 hours of duty, the patient displayed understanding about her condition and learned how to lessen the distress that she experienced.

ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Anorexia
Decrease oral fluid intake
Risk for deficient fluid volume related to inability to meet body requirements and increased metabolic demand.
At the end of 8 hours of duty, the patient will be able to correct the fluid deficit, adequately hydrated, be able to tolerate oral fluids and progress to normal diet.
Evaluate need for intravenous fluids. Maintain IV as ordered.


Calculate maintenance fluid requirements and give oral fluids, IV fluids or both.



Maintain strict intake and output monitoring and evaluate specific gravity at least 8 hours.




Perform daily weight measurement on the same scale at the same time of the day. Evaluate skin turgor.


Assess mucous membranes. Report changes promptly to the physician.


Offer clear fluids chosen by the patient when tolerated.
Previous fluid loss may require immediate replacement.


Assessment ensures
Patient receives appropriate fluids to maintain hydration while transitioning to oral fluids.


Monitoring provides objective evidence of fluid loss and ongoing hydration status.





Further evidence of improvement of hydration status.






Moist mucous membranes provide observable evidence of hydration.



Choice of fluid offered gains the patient’s cooperation.
At the end of 8 hours of duty, the patient was corrected the fluid deficit, hydration is in normal and tolerated the food given.







ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Irritability/ uneasiness
Quietness
apprehensive

Anxiety related to acute illness, hospitalization, uncertain course of illness and treatment and home care needs.
At the end of 8 hours of duty, the patient will be able to verbalize feelings and discomfort and demonstrate behaviors that indicate decrease in anxiety.
Encourage patient to express fears and ask questions; provide direct answers and discuss care, procedures and condition changes.


Explain symptoms, treatment and home care management of COPD.
Provides opportunity to vent feelings and receive timely, relevant information. Establish rapport to gain trust of the patient.


Anticipate potential for recurrence. Assist patient to be prepared about recurrence of the disease after discharge.

At the end of 8 hours of duty, the patient verbalized feelings and discomfort and demonstrated behaviors that indicate decreased anxiety.






ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Request for information
Statements of misconceptions
Knowledge deficit regarding condition, prognosis, treatment, self care, and discharge needs related to information misinterpretation.
At the end of 8 hours of duty, the patient will be able to verbalize understanding about the disease process and participate in treatment regimen.
Determine patient’s perception of the disease process.




Review disease process, cause and effect relationship factors that precipitate symptoms and identify ways to reduce contributing factors. Encourage questions.















Review medications, purpose, frequency, dosage and possible side effects.


Remind patient to observe for side effects if steroids are given on long term basis (ulcers, facial edema and muscle weakness).


Stress importance of proper hand washing techniques.
Establishes knowledge base and provides some insight into individual learning needs.


Precipitating or aggravating factors are individual; therefore the patient needs to be aware of what foods, fluids and lifestyle factors can precipitate symptoms. Accurate knowledge base provides opportunities for patient to make informed decisions and choices about future and control of chronic disease. Although most patients know about their own disease process, they may have outdated information or misconceptions.


Promotes understanding and may enhance cooperation with regimen.



Steroids may be used to control inflammation and to effect a remission of the disease; however, drug may lower resistance to infection and cause fluid retention.
Reduces spread of bacteria

At the end of 8 hours of duty, the patient verbalized understanding about the disease process and participating in the treatment regimen.