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Discussion

Nursing care plan

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??

Featured Replies

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?

  • Expert

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

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