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    NCP Icu

    Uploaded by

    jennelyn losanta
    nursing care plan

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    © All Rights Reserved
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    NCP Icu

    Uploaded by

    jennelyn losanta
    467 views2 pages
    nursing care plan

    Original Title

    NCP ICU

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    nursing care plan

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    467 views2 pages

    NCP Icu

    Uploaded by

    jennelyn losanta
    nursing care plan

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
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    Assessment Nursing Planning Implementation Scientific Rationale Evaluation

    Diagnosis
    Ineffective After 8 hours of Independent: Discharge Outcome:
    Objective: breathing nursing intervention, Assessment
     Dyspnea pattern r/to the patient will be  Assess and record  It is important to take Achieved:
     Increased decreased lung able to: respiratory rate depth action when there is an After 8 hours of nursing
    work of expansion  Maintain an and respiratory effort. alteration in the pattern intervention, the patient
    breathing effective of breathing to detect maintained an effective breathing
     Rapid, breathing pattern early signs of respiratory pattern as evidenced by relax
    shallow  Have a compromise. breathing, absence of dyspnea
    breathing respiratory rate and calm breathing had been
     Nasal flaring and ABG level  Check the patient’s  It is important to be alert observed.
     Vital Signs: within the normal Oxygen Saturation level. on changes on the
    BP: range patient’s condition. Not Achieved:
    Temp:  Report feeling After 8 hours of nursing
    RR: rested and a  Ask if they are “short of  Sometimes anxiety can intervention, the patient can
    HR: feels comfortable breath” and note any cause dyspnea, so breathe normally even without the
     O2 Sat: when breathing dyspnea. watch the patient for “air help of mechanical ventilator
    hunger” which is a sign support.
    that the cause of
    shortness of breath is
    physical.

     Note for changes in level  Restlessness, confusion,


    of consciousness. and/or irritability can be
    early indicators of
    insufficient oxygen to the
    brain.

     Evaluate skin color,  Lack of oxygen will


    temperature, capillary cause blue/cyanosis
    refill; observe central coloring to the lips,
    versus peripheral tongue, and fingers.
    cyanosis.

     Evaluate nutritional  Malnutrition may result


    status (e.g., weight, in premature
    albumin level, electrolyte development of
    level). respiratory failure
    because it reduces
    respiratory mass and
    strength.

    Nursing Management
     Elevate the head of the  Position promotes better
    bed. lung expansion.
     Suction secretions, as  To clear blockage on
    necessary. airway.

    Health Teaching:
     Assist patient to breathe  This increases
    slowly and stay calm. oxygenation and
    Encourage the client to prevents atelectasis.
    sustained deep breaths
    by explaining and
    demonstrating a
    technique on them.

    Collaboration:
     Maintain on mechanical  It helps patient to
    ventilator suuport, as maintain airway.
    prescribed.

     Review ABGs, pulse  To identify some


    oxymetry and serial x- problems that is
    rays. happening to your
    patient.

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