Question

Carlos Mancia, 48yr-old, Spanish speaking migrant worker with no known past medical Hx. r/o Tuberculosis. Vital signs -Temp 99.1, BP 124/62, P 77, RR 20, SaO2 91%. Airborne Isolation. Neuro WNL. Skin moist, respiratory bilateral wheezes and rhonchi. Blood-tinged mucous, productive cough. Diet as tolerated. IV maintenance fluids with D5 1/4 NS @ 150 ml/hr X 3 then reduce rate to 75 ml/hr. Expresses fatigue, fear, concern, and desire for recovery. Need frequent reminder to stay in room and maintain mask precautions. If family/visitors come, will need education to airborne precautions. Spanish interpreter available at extension 61178. Dr. Rondeau

Write a Nursing Care plan. Write a Nursing Care Plan Assessment, Diagnosis, Goal, Implement, Evaluation

Answer 1

NURSING CARE PLAN ASSESSMENT

• Assess cough effectiveness and productivity
• Asses sputum viscosity odour and colour and report findings
• Elevate head part of bed and change position regularly
• Teach patient proper breathing exercises
• Suction when needed
• Maintain adequate hydration
• Nebulization

DIAGNOSIS

Ineffective airway clearance

GOAL

Patient will practice methods to improve airway clearance

Patient will maintain a patent airway

IMPLEMENT

Motivate patient to do breathing exercise

Regular monitoring

EVALUATION

Assess changes

Check the improvement in airway

Check signs of recovery