Sunday, November 28, 2010

Care Plans found in the 17th edition Excelsior CPNE study guide

When writing a care plan use Kardex and what you are assigned.
  • Respiratory Management:
    • Ineffective airway clearance r/t retained secretions aeb ineffective cough, inability to move airway secretions, abnormal breath sound, abnormal respiratory rhythm, rate and depth
      • goal: patient will perform respiration hygiene activities
        • interventions - depend on assigned -
        • Direct patient to perform IS x 10
        • Instruct patient to perform deep breathing and coughing
        • suction secretions
        • assess respiratory status
 Oxygen Management:
  • Impaired gas exchange r/t ventilation - perfusion imbalance aeb oxygen sturation of <93% on room air
    • goal (Outcome) patient will have oxygen saturation equal to or < 93% during PCS
      • monitor oxygen saturation
      • position patient to facilitate respiration
Muscular Skeletal Management:

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