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Nursing Care Plan: Cues Nursing Diagnosis Scientific Explanation Planning Interventions Rationale Expected Outcome

The nursing care plan is for a client with risk of ineffective airway clearance due to tracheal compression. The plan includes interventions to assess respiratory status, position the client in a semi-Fowler's position, and monitor for signs of obstruction. A second diagnosis is a knowledge deficit regarding the client's condition. The plan aims to educate the client on disease prognosis and the importance of medical care through discussion of feelings and determining their current understanding.

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506 views2 pages

Nursing Care Plan: Cues Nursing Diagnosis Scientific Explanation Planning Interventions Rationale Expected Outcome

The nursing care plan is for a client with risk of ineffective airway clearance due to tracheal compression. The plan includes interventions to assess respiratory status, position the client in a semi-Fowler's position, and monitor for signs of obstruction. A second diagnosis is a knowledge deficit regarding the client's condition. The plan aims to educate the client on disease prognosis and the importance of medical care through discussion of feelings and determining their current understanding.

Uploaded by

charmdosz
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

NURSING CARE PLAN

CUES

NURSING DIAGNOSIS Risk for Ineffective Airway Clearance r/t tracheal compression or obstruction

SCIENTIFIC EXPLANATION Pressure on the trachea sufficient to cause displacement and reduction in caliber, usually inside the thorax causing difficulty breathing and swallowing

PLANNING

INTERVENTIONS

RATIONALE

EXPECTED OUTCOME After of nursing intervention, the client will maintain patent airway with aspiration prevented

S> O > presence of visible thyroid gland on anterior neck upon swallowing >gland rises with swallowing

After 30 minutes to 1 hour of nursing intervention, the client will be able to maintain patent airway with aspiration prevented

>assess for dyspnea,stridor, >monitor respiratory rate, depth and work of breathing >auscultate breath sounds, noting presence of rhonchi >encourage client to lie on bed slightly elevated(semifowlers)

>indicators of tracheal obstruction requiring prompt evaluation and interventions >respirations may remain somewhat rapid because of hyperthyroid state, but development of respiratory distress is indicative of tracheal compression >rhonchi may indicate airway obstruction > enhances breathing

CUES

NURSING DIAGNOSIS Knowledge Deficit r/t unfamiliarity with information resources

SCIENTIFIC EXPLANATION lack of cognitive information or psychomotor skills required for health recovery, maintenance, or health promotion

PLANNING

INTERVENTIONS

RATIONALE

EXPECTED OUTCOME After 1 hour of nursing intervention, the client will verbalize understanding of prognosis and potential complications contributes to health

S > hindi ko po alam madam kung ano pwede mangyari dito, di naman masakit, di naman makapunta ng ospital dahil walang pera O > lack of information about the disease process and possible complications of not seeking health care/medical check up

Within 30 minutes to 1 hour of nursing intervention, the client will be able to verbalize understanding of prognosis and potential complications

>encourage verbalization of feelings >determine clients level of understanding of the disease process > avoiding stressful situations and emotional/outburst >educate client the importance of seeking health maintenance

>to note factors contribute to knowledge deficit >to assess clients ability to cope with the learning process >to prevent stress and pressure in making decisions >to further evaluate condition and disease process

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