Nursing care plan

[Dora0507]

please help me in creating a care plan:

32 female

clinical signs

chest problem around 1 week

experience SOB

unable to cough up the secretions on my chest

developed high temp

have red flushed skin,dry craked lips and experience chills

Vital signs;

BP 120/80

temp 39C

PR 98

Thanks

can the nursing dx be ineffective breathing pattern??

[nightnurse808]

Can the pt amb? what is her mobility status?

Continent? Any other si/sx?

What's her o2 sat? is she on o2 nc?? or RA?

[Daytonite, BSN, RN]

can the nursing dx be ineffective breathing pattern?

no. you do not have the evidence to support that a problem of

inadequate ventilation

exists. sob is not enough evidence.

nursing diagnoses that you could use are:

• ineffective airway clearance
  • evidence of this is:
    • sob
      
    • unable to cough up the secretions

  [*]hyperthermia

  • evidence of this is:
    • temp 39c
      
    • pr 98
      
    • red flushed skin
      
    • chills

  [*]impaired oral mucous membrane

  • evidence of this is:
    • dry cracked lips