Question

for the following intervention write 1 intervention to address the problem and 1 intervention for the etiology of the problem.
a.ineffective airway clearance related to thick secretion and decrease Chest expansion secondary to dehydration and pain.
b. Self-Care Deficit: bathing,hygiene,dressing,grooming related to fatigue secondary to disturbed sleep pattern

Answer 1

Ans) a) Nursing Interventions and Rationale
1. Assess sputum for color, consistency, and amount.
2. Assess for clinical manifestations of pneumonia.
3. Provide for maximal thoracic expansion by repositioning, deep breathing, splinting, and
pain management to avoid hypoventilation and atelectasis. If hypoventilation is
present, implement the nursing management plan of care, Ineffective Breathing Pattern
Related to Decreased Lung Expansion.
4. Maintain adequate hydration by administering oral and intravenous fluids (as ordered)
to thin secretions and facilitate airway clearance.
5. Provide humidification to airways via oxygen-delivery device or artificial airway to thin
secretions and facilitate airway clearance.
6. Administer bland aerosol every 4 hours to facilitate expectoration of sputum.
7. Collaborate with the physician regarding the administration of the following:
a. Bronchodilators to treat or prevent bronchospasms and facilitate
expectoration of mucus.
b. Mucolytics and expectorants to enhance mobilization and removal of
secretions.
c. Antibiotics to treat infection.

b) Self caew deficit care plan:

1.Assess patient’s strength to accomplish ADLs efficiently and cautiously on a daily basis using a proper assessment tool, such as the Functional Independence Measures (FIM). The patient may only need help with some self-care measures. FIM measures 18 self-care items related to eating, bathing, grooming, dressing, toileting, bladder and bowel management, transfer, ambulation, and stair climbing.

2.Determine the specific cause of each deficit (e.g., visual problems, weakness, cognitive impairment). Various etiological factors may need more explicit interventions to enable self-care.

3. Guide the patient in accepting the needed amount of dependence. Patient may require help in determining the safe limits of trying to be independent versus asking for assistance when necessary.

4. Present positive reinforcement for all activities attempted; note partial achievements. External resources of positive reinforcement may promote ongoing efforts. Patients often have difficulty seeing progress.

5. Render supervision for each activity until the patient exhibits the skill effectively and is secured in independent care; reevaluate regularly to be certain that the patient is keeping the skill level and remains safe in the environment. The patient’s ability to perform self-care measures may change often over time and will need to be assessed regularly.

6. Implement measures to promote independence, but intervene when the patient cannot function. An appropriate level of assistive care can prevent injury from activities without causing frustration. Nurses can be key in helping patients accept both temporary and permanent dependence.