Upload
jazzmin-angel-comaling
View
222
Download
0
Embed Size (px)
Citation preview
8/13/2019 NCP IAC
1/13
NURSING CARE PROCESS
ASSESSMENT NURSINGDIAGNOSIS
RATIONALE GOAL NURSINGINTERVENTION
RATIONALE EVALUATION
Subjective cues:Nahihirapan nasiya humingadahil sa plemahindi niyamailabas grabena!asi ang ub" niyaneh# as $erbali%edby his m"&her
Objective cues:>difficulty of
breathing
'(hee%es "n
b"&h lung )ields
'pr"du*&i$e *"ugh
+ ,hi&ish *"l"r
'nasal )laring
Ine))e*&i$e air,ay*learan*e rela&ed
&" ine))e*&i$e
*"ugh and
re&ained
se*re&i"ns-
The in)lamma&"ryresp"nse &"
in)e*&i"n *auses
&issue edema and
e.uda&es )"rma&i"n
in &he lungs &he
in)lamma&"ry
resp"nse *an
narr", andp"&en&ially "bs&ru*&
br"n*hial passages
and al$e"li-
Sh"r& Term/
A)&er 0 h"urs ")
nursing
in&er$en&i"ns &he
*lien& ,ill be able
&" main&ain air,ay
pa&en*y-
L"ng Term/
A)&er 1 day ")nursingin&er$en&i"n &he
*lien& ,ill beable &"e.pe*&"ra&e
re&ainedse*re&i"ns andmain&ain n"rmal
'Assessedrespira&"ry
m"$emen&s and use
") a**ess"ry
mus*les-
'M"ni&"red $i&al
signs espe*ially &he
RR-
'Aus*u&a&ed &he
lung s"unds n"&ing
areas ") de*reased
$en&ila&i"n and
presen*e ")
ad$en&i&i"us s"unds-
'M"ni&"red *hes& .
'Use ") a**ess"rymus*les &" brea&he
indi*a&es an abn"rmal
in*rease in ,"r! ")
brea&hing-
'T" "b&ain baseline
da&a- )
'2r"n*hial lung
s"unds are *"mm"nly
heard "$er areas ")
lung densi&y "r
*"ns"lida&i"n-
3ra*!les are heard
,hen )luid is presen&-
'These de&ermine
The *lien&main&ained air,ay
pa&en*y as
e$iden*ed by
e.pe*&"ra&ing *lear
se*re&i"ns readily-
8/13/2019 NCP IAC
2/13
'res&lessness brea&hingpa&&ern-
+ ray rep"r&s-
'En*"uraged *lien&
&" in*rease )luidin&a!e-
'Ad$ised &he
real&i$es ele$a&e &he
head ") bed a& leas&
45 degrees-
'Assis&ed "n
nebuli%er &rea&men&-
Nebuli%a&i"n d"ne
as per d"*&"r6s "rder
e$ery 17 h"urs-'3hes& &apping
pr"gressi"n ") disease
pr"*ess- )
'8ydra&i"n helps
de*rease &he $is*"si&y") se*re&i"ns
)a*ili&a&ing
e.pe*&"ra&i"ns-
'9"si&i"ning )a*ili&a&es
*hes& e.pansi"n and
respira&"ry e))i*ien*y
by redu*ing pressure") abd"minal "rgans
"n diaphragm-
' Rela.es br"n*hial
and u&erine sm""&h
mus*le by a*&ing "n
be&a + adrenergi*
re*ep&"rs-'3hes& physi"&herapy
8/13/2019 NCP IAC
3/13
per)"rmed a)&er
ea*h nebuli%a&i"n-
'Ins&ru*&ed &he*lien& &" ha$e "ral
*are a)&er ea*h
nebuli%a&i"n-
'9r"$ided
supplemen&al )luids
helps &" aid
imm"bili%a&i"n ")
se*re&i"ns-
'Dis*harges )r"m &henebuli%er are ")&en )"ul
&as&ing and smelling-
':luids are regula&ed
&" repla*e l"sses and
aid imm"bili%a&i"n
se*re&i"ns-
ASSESSMENT NURSINGDIAGNOSIS
RATIONALE GOAL NURSINGINTERVENTION
RATIONALE EVALUATION
8/13/2019 NCP IAC
4/13
Sub;e*&i$e Da&a/
Ta&l"ng ara, ngpabali!-? @3
8yper&hermiarela&ed &"in)lamma&"ryresp"nse-
In*rease in b"dy&empera&uregrea&er &hann"rmal range-
En&ry ") &hepa&h"gen in
*ir*ula&"ry sys&em
Regula&i"n ") &".ins
in &he b"dy
Release ") pyr"gen
S&imula&i"n ") &hehyp"&halamus
In*rease "ral&era&i"n ")
&herm"regula&i"n
In*rease in b"dy
&empera&ure
8yper&hermia
A)&er 7 h"urs ")e))e*&i$enursing in&er$en&i"n&he pa&ien&6s&empera&ure ,illde*rease/
'Dem"ns&ra&e&empera&ure ,i&hinn"rmal range )r"m4>-? @3 &" 4B-C@3
8/13/2019 NCP IAC
5/13
'Verbali%edunders&anding ")spe*i)i*in&er$en&i"ns &"pre$en&
hyper&hermia
'9r"$ide TS2 asneeded
'9r"m"&e sur)a*e
*""ling l""sen*l"&hing and *""len$ir"nmen&
'Re$ie, spe*i)i*ris!)a*&"rs *ausessigns andsymp&"ms ,i&h&he in&er$en&i"nsre uired
'Dis*ussimp"r&an*e ")ade ua&e )luidin&a!e andpr"&ein die&
3"llab"ra&i$e/
'Adminis&ermedi*a&i"ns asindi*a&ed &"&rea& underlying*ause su*h as/
'8ea& is l"ss bye$ap"ra&i"n and*"ndu*&i"n-
'8ea& is l"ss by3"n$e*&i"n
radia&i"n and*"ndu*&i"n-
'T" pr"m"&e,ellness
'T" pre$en&dehydra&i"n
'T" &rea&
underlying*auses
8/13/2019 NCP IAC
6/13
8/13/2019 NCP IAC
7/13
8/13/2019 NCP IAC
8/13
diarrhea-
' Res&ar& "ral )luidin&a!e gradually-
O))er *lear li uidsh"urly and a$"id*"ld )luids-
' En*"urage &" ea&
)""ds li!e bananaand apple
' A$"id )""ds &ha&are "ily spi*y and*a))eine-
3"llab"ra&i$e/' Adminis&er an&i