Student visit: ________________________Date:__6/4/2012___Pts Initials:__S.G._Age:_67___Medical diagnosing:__HTN, COPD, malnutrition selective information Collection: Subjective and Objective (List only strong/ aberrant findings)Subjective: Mild dyspnea(R) Lower chest pain in the ass on inspirationWeaknessMalaiseThick white-livered phlegmshakingchillsObjective: Feverweight losscough, bronchial breath soundsshortness of breathCXR shows RLL infiltratesABGs abnormal-CO2 is low| Nursing Diagnosis: toothless Airway Clearance RT excessive, thickened mucous secretions AEB thick, yellow sputum| persevering Goals/Objectives (What do you hope will be the top of your efforts?)| Planned Interventions: (What is indicated for the management of this particular problem? Name cardinal to four priority interventions.)| Rationale: (Why is the interventionIndicated?)| Evaluation of Patient Goals:(Was Pts finis met/ non met/ongoing? Why/why not?)| laconic Term:Effective way of breath, lung ventilation is seemly and in that respect is mobilization of secretions| 1. get on late quick & coughing exercises2. ontogenesis fluid breathing in to at least 2000ml/day3. Administer analgesics | 1. To instigate airway patency2. Hydration basin help liquefy viscous secretions3.
To ameliorate cough when pain is present| Met. Pt. was able to maintain impelling airway by keeping airway patent and efficaciously clearing secretions| gigantic Term:To aid wellness| 1. Encourage & reserve opportunities for rest; limit activities 2. Observe for signs/symptoms of infection3. review article breathing exercises, effective coughing & use of ! supplemental devices much(prenominal) as IPPB or incentive spirometer| 1. Prevents & reduces fatigue2. To mark infectious process & promote timely intervention3. To promote airway patency and the ability to effectively clear the airway| Ongoing. Pt. was improve on different ways to promote self wellness. | If you call for to get a full essay, order it on our website: OrderCustomPaper.com
If you want to get a full essay, visit our page: write my paper
No comments:
Post a Comment