STUDENT NURSES’ COMMUNTY
NURSING CARE PLAN - Bronchitis ASSESSMENT Subjective: “Nahihirapan ako huminga” (Im having difficulty breathing) as verbalized by the patient. Objective: • • • Presence of rhonchi. Ineffective cough. V/S taken as follows: T: P: R: BP: 37.2 79 24 110/80 • Ineffective airway clearance related to excessive, thickened mucous secretions. DIAGNOSIS OBJECTIVE Short term: After 8 hours of nursing interventions the patient will: • Demonstrate improved ventilation and adequate oxygen. Arterial blood gases (ABGs) within normal range. No signs of respiratory distress. INTERVENTION Independent: • Assess respiratory rate, depth. Note use of accessory muscles, pursed lip breathing, Inability to speak. Elevate head of the bed, assist patient assume position to ease work of breathing. Encourage deep slow or pursed lip breathing as individually tolerated or indicated. Routinely monitor skin and mucous membrane color. • Useful in evaluating the degree or respiratory distress and chronicity of the disease process. Oxygen delivery may be improved by upright position and breathing exercises to decrease airway collapse, dyspnea and work of breathing. • Patient display improved ventilation and adequate oxygenation of tissues and Arterial blood gases (ABGs) within normal range and free from symptoms of respiratory distress. RATIONALE EVALUATION
•
•
•
•
•
Long term: After months of nursing interventions, the patient: • Ventilation or oxygenation is adequate to meet self care needs. •
Cyanosis may be peripheral in nail beds or central in lips or earlobes. Duskiness and central cyanosis indicate advanced hypoxemia. Thick, tenacious, copious secretions are major source if ineffective airways. Deep suctioning may be required when cough is ineffective for expectoration of secretions.
Encourage expectoration of sputum; suction when indicated.
•
STUDENT NURSES’ COMMUNTY
• Evaluate level of activity tolerance. Provide calm and quiet environment. • During severe or acute respiratory distress, patient may be totally unable to perform basic self care activities because of hypoxemia and dyspnea. Multiple external stimuli and presence of dyspnea may prevent relaxation and inhibit sleep. Tachycardia, dysrhythmias, and changes in blood pressure can reflect effect of systemic hypoxemia on cardiac function.
•
Evaluate sleep patterns, note report of difficulties and whether patient feels well rested.
•
♦ Monitor vital signs and cardiac rhythm.
•
Collaborative: • Administer supplemental oxygen as indicated by ABG results and patients tolerance. • May correct or prevent worsening of hypoxia.