Nursing Care Plan 1 Jeopardy Template

PREOPERATIVE NURSING CARE PLAN	INTRAOPERATIVE NURSING CARE PLAN	POSTOPERATIVE NURSING CARE PLAN
100 IMPAIRED PHYSICAL MOBILITY R/T NEUROMUSCULAR IMPAIRMENT S/T LEFT HEMIPLEGIC PARALYSIS Patient A is left hemiplegic, unable to perform gross or fine motor skills on the left side of the body, unable to turn to sides without assistance and with independence level: level IV. What nursing problem can you formulate with these cues?	100 RISK FOR ASPIRATION R/T DEPRESSED COUGH/GAG REFLEX S/T INDUCTION OF GENERAL ANESTHESIA Patient A has presence of nasogastric tube, depressed cough and gag reflex, impaired swallowing ability, has coarse crackles at both lung base and is on general anesthesia. Based on thses cues, what possible nursing diagnosis can you formulate?	100 INEFFECTIVE AIRWAY CLEARANCE R/T PRESENCE OF ARTIFICIAL AIRWAY S/T CVA Patient A has presence of tracheostomy, coarse crackle sound was auscultated on both lung base, and fast, shallow respiration was noted when assessed by the student nurse. Upon inspection, pigeon's chest was noted, presence of clear secretions observed around the tracheostomy and respiratory rate was 44 breaths per minute. Based on these cues, what nursing interventions can you formulate for the patient?
200 B. Within 1 hour of nsg interventions, the patient will be able to maintain position of function and no further damage to skin as evidenced by absence of contractures, footdrop and no formation of additional decubitus. Based on the problem Impaired Mobility, what possible objective criteria can you give to this patient? A. Within 1 hour of nsg interventions, the patient will be free of infection. B. Within 1 hour of nsg interventions, the patient will be able to maintain position of function and no further damage to skin as evidenced by absence of contractures, footdrop and no formation of additional decubitus. C. Within 1 hour of nursing interventions, the patient will be able to be free of complications due to impaired oral mucosa such as gingival bleeding,oral thrush, peritonsillar abscess, cracking of lips, etc.	200 C. Within 1 hour of nsg interventions, the patient will be able to experience no aspiration as evidenced by noiseless aspiration as evidenced by noiseless respirations, clear breath sounds and clear, odorless secretions. What possible objective criteria can you give to the patient at risk for aspiration? A. Within 1 hour of nsg interventions, the patient will be able to maintain effective level of fluid volume. B. Within 1 hour of nsg interventions, the patient will be free of injury related to perioperative positioning. C. Within 1 hour of nsg interventions, the patient will be able to experience no aspiration as evidenced by noiseless respirations, clear breath sounds and clear, odorless secretions.	200 A. Within 8 hours of nursing intervention, the patient will be able to maintain patent airway. What possible objective criteria can you give to the patient with Ineffective Airway Clearance? A. Within 8 hours of nursing intervention, the patient will be able to maintain patent airway. B. Within 8 hours of nsg interventions, the patient will be free of injury related to perioperative positioning. C. Within 8 hours of nursing interventions, the patient will be able to be free of complications due to impaired oral mucosa such as gingival bleeding,oral thrush, peritonsillar abscess, cracking of lips, etc.
300 Assess extent of impairment initially and on a regular basis. Inspect skin regularly over bony prominences. Observe affected side for color, edema, or other signs of compromised circulation. As a student nurse, what nursing assessments do you need to employ for this problem Impaired Physical Mobility?	300 Assess for signs and symptoms of aspiration of secretions or gastric contents/fluids. Assess amount and consistency of respiratory secretions and presence of gag or cough reflex. Auscultate lung sounds frequently. As a student nurse, what nursing assessments do you need to employ for this problem Risk for Aspiration?	300 Assess airway patency Evaluate chest movement and auscultate for bilateral breath sound. Assess LOC/ cognition and ability to protect own airway. Assess respiratory rate, O2sat and signs of hypoxia. As a student nurse, what nursing assessments do you need to employ for this problem Ineffective Airway Clearance?
400 Facilitate positioning of the patient or turn patient to unaffected side. Perform passive ROM exercises to all extremities. Facilitate movement using unaffected extremities to support/move weaker side. Support affected body parts or joints using pillows, rolls & foot support. Provide soft mattress or other specialized bed as indicated, ensuring that bed is wrinkled-free. What independent nursing interventions can you give to the patient?	400 Maintain operational suction equipment and suction oral/nasal cavities as needed to clear secretions. Maintain proper positioning of nasogastric tube. Note new onset of abdominal distention or increased rigidity of abdomen. Assist patient in transferring from the OR table to the stretcher and avoid abrupt movements.S What independent nursing interventions can you give to the patient who is at risk for Aspiration?	400 Suction as needed when client is expercieng respiratory distress. Facilitate client positioning periodically. Maintain head of bed elevated 20-30 degrees, semi-fowler’s position Provide oral hygiene Keep environment free from allergens, dust and smoke. What independent nursing interventions can you give to the patient with Ineffective Airway Clearance?
500 Consult with physical therapist regarding active, resistive exercise and client ambulation. What possible collaborative intervention can you give to the patient?	500 Administer antiemetic drugs such as atropine as prescribed by physician. Suction tracheostomy tube as ordered by physician. What dependent nursing interventions can you give to the patient who is at risk for Aspiration?	500 Provide chest physiotherapy as indicated such as postural drainage and percussion. Administer aerosol bronchodilators as indicated. Administer O2 as prescribed. What dependent nursing interventions can you give to the patient with Ineffective Airway Clearance?

NURSING CARE PLAN

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