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Showing posts with label Ineffective Breathing Pattern. Show all posts
Showing posts with label Ineffective Breathing Pattern. Show all posts

Monday, December 1, 2014

Ineffective Breathing Pattern and Altered Urinary Elimination r/t Glomerulonephritis


Nursing Care Plan for Glomerulonephritis

Nursing Diagnosis : Ineffective breathing pattern related to the inflammatory process.
characterized by : the patient complained of shortness of breath.

Expected outcomes :
Demonstrate effective breathing patterns, shortness of reduced or lost.

Intervention and Rationale :
1. Assess respiratory frequency and depth of chest expansion.
R / : Frequency of breath usually increased, dyspnea and an increase in breath work. Limited chest expansion indicates the presence of chest pain.

2. Elevate the head position and aids in changing the position.
R / : higher head position enables lung expansion and ease breathing. Changing the position of improving charging different lung segments which improves the gas diffusion.

3. Helping patients overcome fear in breathing.
R / : Fear breathe increase occurs hypoxemia.

4. Collaboration in the provision of supplemental oxygen.
R / : Maximizing breathing and lower the breath work.


Nursing Diagnosis : Altered Urinary Elimination related to capacity or bladder irritation secondary to infection.
characterized by oliguria / anuria.

Expected outcomes :
Shows the continuous flow of urine with adequate urine output for individual situation.

Interventions and Rational
1. Record the complaint urine (slight decline / cessation of urine flow suddenly)
R / : Decrease sudden flow of urine may indicate obstruction / dysfunction.

2. Observe and record the color of urine, hematuria note.
R / : Urine can be a bit pink.

3. Keep an eye on vital signs.
R / : fluid balance indicator shows the level of hydration and fluid replacement therapy effectiveness.

4. Collaboration in the administration of intravenous fluids.
R / : Helps maintain hydration / circulation adequate volume and the flow of urine.

Ineffective Tissue Perfusion related to Glomerulonephritis

Sunday, October 5, 2014

Ineffective Breathing Pattern related to Epilepsy (Seizures)


Nursing Care Plan for Epilepsy (Seizures)

Nursing Diagnosis for Epilepsy (Seizures) : Ineffective breathing pattern related to neuromuscular damage, increased mucus secretion

Goal : Maintain effective breathing pattern with a patent airway.

Interventions :

1. Encourage clients to vacate the mouth of objects / substances specified / dentures or other devices if the aura phase occurs and to avoid jaw shut if seizures occur without marked symptoms of early.
Rationale : Lowering the risk of aspiration or the entry of foreign objects into the pharynx.

2. Place the client in a position incline, flat surface, tilt the head during a seizure attack.
Rationale : Increase the flow (drainage) secret, preventing the tongue falls to clog the airway.

3. Remove clothing in the area of the neck, chest, and abdomen.
Rationale : To facilitate the effort to breathe.

4. Enter the tongue spatula / artificial airway or soft object rolls as indicated.
Rationale : Prevent being bitten tongue and facilitate during a suction mucus. Artificial airway may be indicated after the easing of seizure activity if the patient is unconscious and can not maintain a safe position of the tongue.

5. Do suction mucus as indicated.
Rationale : Lowering the risk of aspiration or asphyxia.

6. Give supplemental oxygen / ventilation manually as needed on postictal phase.
Rationale : Cerebral hypoxia may decrease as a result of decreased circulation or oxygen secondary to vascular spasm during seizures.

7. Prepare / aids to intubation if indicated.
Rationale : The emergence of prolonged apnea in postictal phase requiring mechanical ventilator support.

Sunday, September 14, 2014

Ineffective Breathing Pattern - NCP for Acute Myocardial Infarction


Nursing Care Plan for Acute Myocardial Infarction

The term myocardial infarction pathologically denotes the death of cardiac myocytes due to extended ischemia, which may be caused by an increase in perfusion demand or a decrease in blood flow. AMI falls in the spectrum of acute coronary syndromes (ACS), which includes unstable angina (UA), non–ST-elevation myocardial infarction (NSTEMI), and ST-elevation myocardial infarction (STEMI)

Persistent elevation of the ST-segment on ECG signifies total occlusion of a coronary artery that causes necrosis of the myocardial tissue. This condition is STEMI. ACS without ST-segment elevation may either be NSTEMI or UA

NSTEMI is more severe than UA. In this condition, the ischemia in the cardiac tissue is extensive enough to release cardiac biomarkers (troponin I or T) into the blood, but the occlusion is not as complete enough to cause elevation of the ST-segment.(www.clinicalkey.com)


Nursing Diagnosis for Acute Myocardial Infarction

Ineffective Breathing Pattern related to hyperventilation, anxiety

Goal :
Breathing pattern becomes effective

Outcomes :
  • Demonstrate effective cough and breath sounds were clean, no cyanosis and dyspnea (able to produce a sputum sample, is able to breathe easy, no pursed lips)
  • Showed a patent airway (the client does not feel suffocated, the rhythm of breath, respiratory frequency in the normal range, no abnormal breath sounds)
  • Vital signs within normal range.

NIC

Airway Management :
  • Open the airway, use techniques jaw thrust or chin lift if necessary.
  • Position the patient to maximize ventilation.
  • Identification of patients need artificial airway equipment installation.
  • Attach mayo if necessary.
  • Perform chest physiotherapy.
  • Remove the secret by coughing or suctioning.
  • Auscultation of breath sounds, note the presence of additional noise.
  • Perform suction on the mayo.
  • Give bronchodilators if necessary.
  • Give a humidifier.
  • Set intake to optimize fluid balance.
  • Monitor espirasi and O2 status.

Respiratory Monitoring :
  • Monitor the average depth, rhythm and expiratory efforts.
  • Note the movement of the chest, observe symmetry, the use of additional muscles, supraclavicular and intercostal muscle retraction.
  • Monitor breath sounds like snoring.
  • Monitor breathing patterns : bradipnea, tachypnea, kusmaul, hyperventilation, cheyne stokes, biot.
  • Note the location of the trachea.
  • Monitor the diaphragm muscle fatigue (paradoxical movement).
  • Auscultation of breath sounds , note areas of decreased / no ventilation or extra sound.
  • Determine the need auscultation suction with crakles and crackles, in the main airway.
  • Auscultation of lung sounds after the action to find the results.