OK, so I went to clinical and now have my first care plan due tomorrow. I am utterly clueless on how to do this... I really need help..
Here is my client's information:
Medical Diagnosis: CVA
(other diagnoses include Hypertension, CAD, Hyperlipidemia, Angina, Dermatitis) She also has a trach and a peg tube.
She is practically non-responsive. She can't move her body or speak. She is a total care patient. She doesn't have a foley, her oxygen is at 10 l/min via trach. She has all nutrition via her PEG, doesn't have an IV.
I figure that one of the most important things is Ineffective Airway Clearance, but I don't have a r/t statement by it could be aeb SOB? I really don't know...
Any assistance would be helpful..
the correct sequence for your diagnoses is:
- ineffective cerebral tissue perfusion r/t interruption of blood flow aeb changes in motor responses.
- you should specify what those specific changes are
- ineffective airway clearance r/t retained viscous secretions aeb rhonchi on inspiration.
- impaired physical mobility r/t neuromuscular involvement aeb inability to purposefully move involved body parts
- you should name specific body parts and what they cannot do
- self-care deficit r/t neuromuscular impairment aeb inability to perform adl's.
- since you are combining all 4 diagnoses into one you should specifically list what these adls are in your aeb section
- impaired verbal communication r/t neuromuscular impairment aeb inability to produce verbal communication.
when someone comes along and reads a nursing diagnostic statement on a care plan, it is like a photograph. they should get a good mental picture of what is going on with that patient. saying something like self-care deficit r/t neuromuscular impairment aeb inability to perform adl's
leaves me with a lot of questions. if i'm the director of nursing reading that, i shouldn't have to actually go into that patient's room and do an assessment myself to see what adls they can't do.
- - - - - - - - - - - - - - -
my supportive/assessment data for ineffective airway clearance r/t retained viscous secretions aeb rhonchi on inspiration.
my supportive/assessment data for ineffective airway clearance is
-trach in place
-oxygen at 10 l/min
-yellow viscous secretion produced by coughing
-rhonchi on inspiration
goal: client will maintain patent airway with breath sounds clear
interventions/rationales: (((i don't know this part yet....))))
- your diagnostic statement should include all the symptoms: ineffective airway clearance r/t retained secretions aeb rhonchi on inspiration and productive cough of yellow viscous secretions
- a tracheostomy and oxygen are medical treatments - not symptoms of the inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway, the definition of ineffective airway clearance (page 308, nanda international nursing diagnoses: definitions and classifications 2009-2011).
- your nursing interventions target the patient's symptoms: the rhonchi and productive cough. so think about what you, nurse, are going to do for that cough and to help the patient clear those rhonchi (actually it's the secretions from their lungs).
- your goals are a prediction of what will happen when your nursing interventions are carried out
- here's an example of a goal and interventions for this diagnoses (warning: this may not apply to your patient and some are independent and some dependent on md order type interventions)
(is what you predict will happen as a result of the interventions being performed): patient will demonstrate how to correctly cough and deep breath by the end of the day.
(they have to address the aebs and the r/ts):
- assess level of consciousness and orientation to person, place and time
- inspect the chest for abnormal movements with breathing
- inspect the extremities for cyanosis, edema and clubbing of the digits
- auscultate the lungs for diminished, absent and adventitious breath sounds q shift
- monitor for increasing lethargy
- have the patient sit upright to ease their breathing
- encourage the patient to drink plenty of fluids to stay hydrated and use humidification
- give oxygen, bronchodilators, mucolytics, expectorants and antibiotics as ordered and as needed
- explain the importance of coughing and deep breathing
- teach coughing and deep breathing exercises
[font=courier new]o coughing
take a slow deep through the nose and expand the chest fully
breathe out through the mouth feeling the chest sink down and in
take a second slow breath through the nose expanding the chest fully and breathing out
take a third breath in the same way but hold it
the patient should now cough two or three times (once is usually not enough) and concentrate on using the diaphragm to force the air out
follow with several normal breaths exhaling slowly
do this every 2 hours
[font=courier new]o deep breathing
lie supine with legs slightly bed at the knees; can also be done sitting and standing
take as deep breath as possible through the nose and allow the abdomen (not the chest) to rise
hold the breath for a count of five
exhale completely through pursed lips as if whistling allowing the ribs to sink downward and inward
rest several seconds and repeat 5 to 10 times every hour
- teach about the underlying diagnosis and treatment plan
Last edit by Daytonite on Feb 15, '10