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Showing posts with label Ineffective breathing pattern. Show all posts
Showing posts with label Ineffective breathing pattern. Show all posts

11 Feb 2014

1. Ineffective airway clearance: Bronchitis Nursing Care Plans

1. Ineffective airway clearance
related to: increased production of secretions.
As evidenced by:[Check those that apply]
Major:
(
Must be present)
(_) Ineffective cough.
(_) Inability to remove airway secretions.
Minor:
(
May be present)
(_) Abnormal breath sounds.
(_) Abnormal respiratory rate, rythm, depth.

Date &
Sign.
Plan and Outcome[Check those that apply]Target
Date:
Nursing Interventions[Check those that apply]Date
Achieved:
The patient will:
(_) Maintain patent airway A.E.B.:
  • Clear breath sounds or breath sounds consistent with own baseline.
  • Respirations easy and un-labored.
  • Normal resp. rate.
(_) Other:
(_) Assess respiratory rate, depth, rythm, effort, and breath sounds q ___ hours.
(_) Position: HOB elevated ___ degrees.
(_) Promote optimum level of activity for best possible lung expansion:
  • Ambulate q ___ for ___ min.
  • Chair q ___ for ___ min.
  • Turn/reposition q ___.
(_) Suction q ___ hours (and prn) per:
  • Nasal

4. Ineffective breathing pattern: Bronchitis Nursing Care Plans

4. Ineffective breathing pattern
related to: bronchoconstriction, mucus.
As evidenced by:[Check those that apply]
Major:
(
Must be present)
(_) Changes is respiratory rate or pattern from baseline.
(_) Changes in pulse (rate, rythm).
Minor:
(
May be present)
(_) Orthopnea (_) Tachypnea (_) Hyperpnea
(_) Splinted, guarded respirations.

Date &
Sign.
Plan and Outcome[Check those that apply]Target
Date:
Nursing Interventions[Check those that apply]Date
Achieved:
 The patient will:
(_) Demonstrate an effective respiratory rate, depth, and pattern A.E.B.:
  • Color pink/ absence of cyanosis.
  • Absence of diminished breath sounds.
(_) Other:
 (_) Assess color, respiratory rate, depth, effort, rythm and breath sounds q ___ hours.
(_) Position to facilitate optimum breathing patterns:
  • HOB elevated ___ degrees.
  • Turn q ___ hours.
(_) Cough and deep breath q ___ hours.
(_) Increase activity as tolerated to promote maximum diaphragmatic excursion
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