X.

NURSING CARE PLAN CUES/ DATA NURSING DIAGNOSIS Ineffective tissue perfusion (Peripheral) related to increased blood viscosity secondary to hyperglycemia as manifested by fatigue, cyanotic finger beds, BP of 180/80 and CBG monitoring of 346 mg/dl. RATIONALE GOALS/ OBJECTIVES NURSING INTERVENTIONS Independent: - Assess color, sensation, movement, capillary refill, and peripheral pulses via Doppler on extremities with circumferential burns. Compare with findings of unaffected limb. RATIONALE EVALUATION

Objective: -Fatigue -Cyanotic finger beds - weakness -dizziness - pitting edema at upper arms and hands. ( 3+) - pale lips -V/S taken as follows: T: 35.5 PR: 126 RR: 23 BP: 180/80 02 SAT: 91% CBG monitoring: 346 mg/dl

Short term goals: Perfusion is the After 8 hours of ability for blood to thorough circulate through nursing intervention, the body the unimpeded. client will be able to: a.) Decrease blood Hypergylcemia glucose level from causes viscosity of 346mg/dL within the blood normal range of 80120 mg/dL slow circulation or b.) Improve circulation travel of blood within finger beds within the body to c.) Reduce edema at supply tissues upper arms and hands from (3+) to (2+). Long term goals: Inadequate tissue a.) A. Completely perfusion eliminate presence of pitting REFERENCE: edema. b.) Maintain normal Brunner and blood glucose level of suddarths medical 80 - 120mg/dl. surgical nursing 12th edition. Vol.1

-Edema formation can readily compress blood vessels, thereby impeding circulation and increasing venous stasis and edema. Comparisons with unaffected limbs aid in differentiating localized versus systemic problems such as hypovolemia and decreased cardiac output. -Promotes systemic circulation and venous return, and may reduce edema or other deleterious effects of constriction of edematous tissues. Note: Prolonged elevation can impair arterial perfusion if BP falls or tissue pressures rise excessively. -Promotes local and systemic circulation. -Cardiac dysrhythmias can occur as a result of electrolyte shifts, electrical injury, or release of myocardial depressant factor, compromising cardiac output and tissue perfusion

-Elevate affected extremities, as appropriate. Remove jewelry or arm band.

After 8 hours of thorough nursing intervention, the client was able to: a.) Decreased blood glucose level from 346mg/dL within normal range of 80-120 mg/dL b.) Improves circulation within finger beds c.) Reduces edema at upper arms and hands from (3+) to (2+).

-Encourage active ROM exercises of unaffected body parts. - investigate irregular impulses.

-- Provide skin care; avoid use of soaps and alcohol based lotions.

-removes waste products from skin while preventing dryness of skin. - to prevent pressure sores, improves circulation and Tapping the back to clear chest congestion is called chest physical therapy and can assist in loosening mucus so that your body can expel it through coughing.

- turn patient every 2 hrs. And provide back tapping.

- Dependent -Administer medication as prescribed. ( Apidra 8 units SQ and humalog 30 - Insulin helps lower down units SQ ) blood glucose.

REFERENCE: Brunner and suddarths medical surgical nursing 12th edition. Vol.1

CUES/ DATA

NURSING DIAGNOSIS

RATIONALE Time-limited disruption of sleep. The most common cause of this is the nursing care given at night on patients for monitoring purposes and therapies or medications needed to be administered during this time. Change in sleep- wake schedule Decreased REM Impaired processing of information in the brain Decreased oscillations Disturbed sleeping pattern REFERENCE:

GOALS/ OBJECTIVES Goal: Achieve a normal sleeping pattern. Objectives: After 2 days of effective nursing intervention the pt. will be able to: A. Wake up less frequently during night B. to rest and reduce dizziness C. have a stable vital signs

NURSING INTERVENTIONS Independent: >Provide back massage before bedtime

RATIONALE

EVALUATION

Objective: -Fatigue -drowsiness -Restlessness -V/S taken as follows: T: 35.5 P: 126 R: 23 BP: 180/80 Disturbed sleep pattern r/t interruptions for therapeutics and monitoring.

>Keep environment quiet for sleeping >Keep the room dim to promote the secretion of hormones that regulates sleepiness which is melatonin

Objectives: After 2 days >Use of back massage has of effective nursing been shown effective for intervention the goal was promoting relaxation, which partially met. The patient likely leads to improved sleep was able to: A. Wake up less >Excessive noise disrupts frequently during night sleep B. Maximizes rest and reduces dizziness >Production of melatonin by C. have a stable vital the pineal gland (tryptophan signs is converted into serotonin and then into melatonin) is inhibited by light and permitted by darkness - So that patient will have an understanding of the importance of care being done to him. Minimizes complaints

-Explained necessity of disturbances for monitoring VS and care when

-Fundamentals of Nursing by Taylor, page 1178 -Nursing Diagnosis Handbook, B. Ackley & G. Laedwig, 7th edition

hospitalized. - Provide warm bath before going to sleep -Gives comfort to the patient and helps warm up the body REFERENCE: -Fundamentals of Nursing by Taylor

CUES/ DATA Subjective: SN: Nay nahihirapan po bang huminga? Pt. Oo. (nodding) As verbalized by the patient. Objective: -Patient is in mechanical ventilator inserted at the mouth. - (+) use of accessory muscles (+) secretion when suctioning characterized by

NURSING DIAGNOSIS Ineffective breathing pattern r/t increased production of secretion as evidenced by (+) secretion when suctioning characterized by yellowish sputum with a gush of blood.

RATIONALE The invading organism causes sx in part by provoking an overly exuberant immune response in the lungs. The small blood vessels in the lungs (capillaries) become leaky and protein-rich fluid seeps into the alveoli this results in a less functional area for 02-C02 exchange. The patient becomes relatively 02 deprived while retaining potentially damaging carbon dioxide. The patient breaths faster and faster in an effort to get on

GOALS/ OBJECTIVES Goal: improvement of breathing pattern Objectives: After 30 minutes of nursing intervention, the patient will be able to: A. Show signs of decrease respiratory effort as manifested by RR from 26 to 20 cpm. And an 02 sat from 91 % to 96 %. B. Decrease restlessness thus must have a comfortable position while sleeping.

NURSING INTERVENTIONS Independent: -Establish rapport

RATIONALE

EVALUATION

-Position the patient in semi fowlers to high fowlers as needed.

- It is important to gain patients trust and cooperation and as well as helps reduce anxiety thus limiting the workload of the heart and 02 demand. - An upright position promotes lung expansion and mobilization of secretion. ( law of gravity)

-Frequent repositioning prevents pooling and stasis - Reposition the patient of secretion thus helping in every 2 hrs and provide mobilization of secretion. back tapping while on lateral position. - Frequent assessment

Objectives: After 30 minutes of nursing intervention, the goal was partially met. The patient was able to: A. Show signs of decreased respiratory effort as manifested by RR from 26 to 20 cpm. And an 02 sat from 91 % to 96 %. B. Decreased restlessness thus must have a comfortable position while sleeping.

yellowish sputum with a gush of blood. -observed the patient coughs and having times of difficulty breathing. -restlessness -V/S taken as follows: PR: 126 RR: 26 BP: 180/80 02 SAT: 91%

02 and off more C02. -Assess and monitor vital signs - Maintain fluid intake at least 1000 ml / day within cardiac tolerance with oral intake is resumed. And use warm water as needed. -Suction the patients secretion before feeding and PRN.

provides information about any improvement or deterioration of patients condition. -Provides ongoing estimate of volume Replacement needs. Warm water aid in mobilization of secretion.

REFERENCE: http://science.jrank.org/pa ges/5 358

- Helps to clear out the secretion in the lungs thus promoting good 02 and C02 exchange within the capillaries. - To prevent the mouth on getting dry thus giving the patient discomfort as well as to prevent sores within the location of the mechanical ventilator that can cause infection and for sanitary purposes. - To determine if secretion reduces or worsens within the lungs. - promotes rest and sleep and prevents anxiety thereby decreasing the patients 02 demand. -Some degree of

-Moist and cleanse the mucous membrane and lips using a wet cotton.

-Auscultate the lungs for breath sounds - Maintain a quiet,comfortable environment. -Auscultate breath

sounds. Note for adventitious breath sounds such as crackles.

bronchospasm is present with obstruction of airway

- Mechanical ventilator is the one who helps the - Monitor and check patient to breathe thus any mechanical ventilator insufficiency leads to for patency and kinks if further complication or needed. injury and gives the patient discomfort.

DEPENDENT: -Administer medication as prescribed.

-Bronchodilators aid in reduction of bronchospasm, anti inflammatory drugs (solucortef 100mg IV reduces inflammatory Q8h, Anti response of the body thus inflammatory , Seretide reducing the production of 250 mcg, pulmodual mucus. neb 7gtts +3cc NSS Q4 before suctioning and REFERENCE: feeding or PRN Brunner and suddarths Bronchodilator) medical surgical nursing 12th edition. Vol.1

CUES/ DATA

NURSING DIAGNOSIS Ineffective airway

RATIONALE

OBJECTIVES:

Inhalation of the

GOALS/ OBJECTIVES Goal: improvement of airway clearance.

NURSING INTERVENTIONS Independent: - Assess RR and 02

RATIONALE

EVALUATION

-Provides baseline data in

After 30 mins of

-(+) crackles at the lower quadrant of both left and right lungs. - (+) use of accessory muscle - Patient has mechanical ventilator inserted at the mouth - (+) secretion when suctioning characterized by yellowish sputum with a gush of blood. -observed the patient coughs and having times of difficulty breathing. -restlessness -V/S taken as follows: PR: 126 RR: 26 BP: 180/80 02 SAT: 91%

clearance r/t copious tracheobronchial secretions as manifested by (+) crackles at the lower quadrant of both left and right lungs

microorganism from the environment (CAP) Inflammatory reaction in the alveoli Producing exudates Occurrence of tracheobronchial secretions

saturation Objective: After 30 mins of nursing intervention the patient will be able to: A. exhibit a non labored breathing as manifested by RR from 26 to 20 cpm and an 02 sat of 91% to 95%. B. Absence of crackles at both lungs C. Maintain a patent ET tube. D. Reduce restlessness -Ausculate the lungs for breath sound.

evaluation adequacy of ventilation . - To determine if secretion reduces or worsens within the lungs and use to identify the location of secretions.

- An upright position promotes lung expansion and mobilization of secretion. ( law of gravity) - Frequent assessment - Assess and monitor vital provides information about signs any improvement or deterioration of patients condition. - Position the patient in semi fowlers to high fowlers as needed. - Reposition the patient every 2 hrs and provide back tapping while on lateral position. - Maintain fluid intake at least 1000 ml / day within cardiac tolerance with oral intake is resumed. And use warm water as needed. - Frequent repositioning prevents pooling and stasis of secretion thus helping in mobilization of secretion. - Provides ongoing estimate of volume Replacement needs. Warm water aid in mobilization of secretion.

nursing intervention the goal was partially met. The patient was able to A. exhibited a non labored breathing as manifested by RR from 26 to 20 cpm and an 02 sat of 91% to 95%. B. Manifest the Absence of crackles at both lungs C. Maintained a patent ET tube. D. Reduced restlessness

REFERENCE: Brunner and suddarths medical surgical nursing 12th edition. Vol.1

- Maintain a quiet,comfortable environment.

- promotes rest and sleep and prevents anxiety thereby decreasing the patients 02 demand.

- Suction the patients secretion before feeding and PRN.

- Helps to clear out the secretion in the lungs thus promoting good 02 and C02 exchange within the capillaries. -To prevent the mouth on getting dry thus giving the patient discomfort as well as to prevent sores within the location of the mechanical ventilator that can cause infection and for sanitary purposes.

- Moist and cleanse the mucous membrane and lips using a wet cotton.

- DEPENDENT: -Administer medication as prescribed. (solucortef 100mg IV Q8h, Anti inflammatory , Seretide 250 mcg, pulmodual neb 7gtts +3cc NSS Q4 before suctioning and feeding or PRN Bronchodilator) -Bronchodilators aid in reduction of bronchospasm, anti inflammatory drugs reduces inflammatory response of the body thus reducing the production of mucus

COLLABORATIVE: -Obtain sputum specimen for culture sensitivity test

- to identify the bacteria present thus helping to determine what kind of medication will be given as

well as to know the progression or deterioration of the patients condition.

REFERENCE: Brunner and suddarths medical surgical nursing 12th edition. Vol.1

CUES/ DATA

NURSING DIAGNOSIS

RATIONALE

GOALS/ OBJECTIVES

NURSING INTERVENTIONS

RATIONALE

EVALUATION

Objectives: - pitting edema at upper arms and hands. ( 3+) -Dry skin - Prolonged stay in bed because of fatigue and cant tolerate activities thus increasing 02 demand - Extremes of age (75 years old) Impaired skin integrity r/t physical immobilization as manifested by Prolonged stay in bed because of fatigue and cant tolerate activities since it increases 02 demand. Immobility, which leads to pressure, shear, and friction, is the factor most likely to put an individual at risk for altered skin integrity. The normal loss of elasticity; inadequate nutrition; environmental moisture, especially from incontinence; and vascular insufficiency potentiate the effects of pressure and hasten the development of skin breakdown. Groups of persons with the highest risk for altered skin integrity those who are confined to bed or wheelchair for prolonged periods of time and those with edema.

Objectives: After 6-8 hrs of nursing -Inspect bed folds and interventions, the unclean linens. patient will be able to: - Reduce the risk for further impairment of skin integrity. - Patients caregiver will demonstrate understanding and skill in proper care of the patients skin. -maintain clean and healthy skin - Keep patients fingernails short and smooth. - Provide skin care; avoid use of soaps and alcohol based lotions. - Massage every 2 hours with emollients; turn patient every 2 hrs. -Assess skin integrity every 4- 8 hrs. - Restrict sodium as prescribed. - It may cause friction that may trigger the development of pressure ulcers and lesions. -Prevent skin excoriation and infection from scratching. -removes waste products from skin while preventing dryness of skin. -Promotes immobilization of edema and prevention of pressure sores at the back as well to promote circulation. After 6-8 hrs of nursing interventions the goal was met. The patient was able to: - Reduced the risk for further impairment of skin integrity. - Patients caregiver will demonstrated understanding and skill in proper care of the patients skin.

-Edematous skin and tissue have compromised nutrient -maintained a supply and are vulnerable to clean and healthy pressure and trauma. skin -Minimizes edema formation and sodium holds water that causes fluid to be trapped in the body tissues.

Reference: Nurses

- Perform passive

- Also promotes

Pocket Guide by Doenges, Moorhouse, Murr

range of motion exercises every 4 hrs; elevate edematous extremities whenever possible. - Eat fruits and vegetables

mobilization of edema and circulation of the blood.

-Textbook of medical surgical Nursing by Brunner and suddarths

- Will help in proper nourishment of the skins dryness with the limited amt of water. -Injury to the skin over swollen areas takes longer to heal and is more likely to become infected.

- Protect any swollen areas from additional pressure, injury, and extreme temperatures.

Reference: Nurses Pocket Guide by Doenges, Moorhouse, Murr -Textbook of medical surgical Nursing by Brunner and suddarths.