Question

Write a care plan for a patient with Collapsed left lung and severe aspiration pneumonia.

- Write 3 nursing diagnosis, 5 interventions with rationale , 2 goals (long term and short term)

patient info-

BP = 160/90     .     pulse = 93     ,    temp = 98.3 f    ,    respiration = 18

if possible please provide with 2 - 3 nursing notes.

Answer 1

Case of collapsed left lung and severe aspiration pneumonia. Vitals are :-

Temperature - 98.3 °F

Respiratory rate - 18bpm

Blood pressure- 160/90 mmhg

Heart rate - 93bpm

# Nursing diagnosis :-

Ineffective airway clearance related to increased respiratory secretions

Short term goal - after the provision of nursing intervention ,there will be expectoration of secretion and mobilization of mucus

Long term goal -is to expand the lungs

Nursing interventions with rationale:-

1. Assess the vitals of the patient

Rationale - to manage any abnormal vitals at its early stage without complications -

2. auscultate lung field and note areas where there is decreased lung or absence of lung sounds

Rationale - it will help to evaluate the adequacy of adequate ventilation.

3. encourage deep breathing exercises

Rationale - deep breathing promotes oxygenation

4. increase the fluid intake as appropriate for the patient

Rationale - fluid helps to loosen the thick secretions and facilitates the expectoration of mucus .

5. Assist patient to do coughing exercise

Rationale - coughing helps to secrete out the secretions

6. Provide the patient semi -fowlers position

Rationale - Fowler's position helps to expand the lungs

7. Provide patient chest physiotherapy and postural drainage

Rationale - chest physiotherapy helps to loosen the thick secretions and postural drainage allows drainage of secretions and lung expansion

#. Nursing diagnosis :-

Impaired gas exchange related to construction of airway by secretions

Short term goal - after implementation of intervention patients will have normal ABG values

Long term goal - to allow the drainage of mucus and expand the airways .

Nursing interventions :-

1. Assess the vitals including SPO2 ,ABG values

Rationale - to identify hypoxia ,if present and to take emergent action

2. Monitor skin and mucous membrane

Rationale - shakiness and central cyanosis indicate hypoxemia

3. Auscultation of breath sound and note areas of wheeze and suppressed breath sounds.

Rationale - presence of wheeze indicate bronchospasm and retained secretions

4. Provide patient upright position -semi Fowler's

Rationale - upright position increases oxygen delivery by expansion of lungs

5. Suction when ever needed

Rationale - suctioning is done when cough is ineffective to excrete out the secretions

# Nursing diagnosis :-

Acute pain related to persistent cough and inflammation

Short term goal - after implementation of interventions there will decrease in pain , patient will have patent airway

Long term goal - to reduce the inflammation and absence of dyspnea

Nursing interventions :-

1. Elevate head end of the bed and change position frequently

Rationale - exapnasion of lungs and expectoration of secretions

2. Advice patient to do deep breathing exercise

Rationale - deep breathing enhances expansion of my G's and removal of secretions

3. Advice patient to splint the chest while doing coughing exercise

Rationale - splinting the chest during coughing helps to reduce chest discomfort and pain

4. Encourage intake of more fluids and especially warm fluids.

Rationale - warms fluids will help to loosen secretions and expectoration of them

5. Administration of medications as advised - antibiotics ,mucolytic and expectorants

Rationale - it will help in decreasing bronchospasm and mobilization of secretions .