Nursing Care Plan: Risk For Ineffective Airway Clearance Related To Bleeding From Tonsillectomy Short Term

NURSING CARE PLAN
Cues Nursing Analysis Goals Intervention Rationale Evaluation

Diagnosis
Subjective: Risk for Ineffective airway Short term: Perform nursing a. Promotes 1. Was the
 “nahihirapan Ineffective clearance is the care drainage of patient able to
po akong Airway inability to clear - The patient and continuous blood and breath properly
clearance secretions or will appear monitoring of unswallowed __ Met
huuminga”
__ Unmet
related to obstructions from relaxed and able patient’s vital signs saliva from the
__Partially met
Objective: bleeding from the respiratory tract to rest/sleep and pain scale. mouth that can
 BP-110/70 tonsillectomy to maintain a clear comfortably potentially be 2. Was the health
 PR-96bpm airway. Independent aspirated. care provider able
 RR=23cpm - The patient will a. Help patient to explain in her
 02 sat 96%. Post tonsillectomy report gain of to a comfortable b. Providing own words the
is an uncommon, knowledge position, prone or health teaching importance of the
 Patient
but a potential life- about tonsilitis side-lying to the patient treatment?
frequently
threatening event, position. and family aids
swallows __Met
in which it causes b. Educate the in coping with
__Unmet
airway obstruction patient and disease
__Partially met
and hypovolemic his/her family condition and
shock. It has two about the causes helps to prevent 3. Were all the
types of of tonsilitis, ways further nursing
hemorrhage: the to prevent complications. interventions
primary and recurrence. appropriate to the
secondary. c. encourage c. Hydration client’s condition?
patient to drink loosens thick
Primary fluids. secretions or __Met
__Unmet
hemorrhage occurs d. Administer maintains the
__Partially met
within 24 hrs of the medication such secretions moist
procedure, while Long term: as antibiotics as to facilitate easy
secondary occurs - The patient per doctor’s removal.
after more than 24 will prevent order.
hrs from the reoccurrenc d. Prevent an
procedure and is e of Dependent: infection caused
commonly seen tonsilitis a. The nurse by bacteria.
between day 5 & could advise the
day 10 post-op client to go to the
Reference: hospital or to the Dependent:
Handbook for client’s Physician a. When you see
Brunner & to be provided of your doctor
appropriate
Suddarth’s, regularly, they
prescription for
Textbook of can detect
post-op tonsilitis
Medical-Surgical or to other health
Nursing, 10th ed patients’ illness conditions or
Nurse’s pocket that are diseases early.
th
guide 14 edition, appropriate for Early detection
2016, page 600, postsurgical gives you the
Wiley Blackwell patients or other best chance for
health getting the right
Starship, (2018), management treatment
tonsillectomy- procedures. quickly,
management of Collaborative: avoiding any
post-tonsillectomy a. Refer the complications.
bleeding in CED, patient to a
retrieved from doctor to have a Collaborative:
https://www.starshi follow-up to a. Regular
p.org.nz/guidelines/ assessment of checkups can help
tonsillectomy- tonsils and to find potential
management-of- ensure no health issues
post-tonsillectomy- reoccurrence of before they
bleed-in-ced/ bleeding. become a
problem. Seeing
your doctor
regularly, can
help detects
health conditions
or
diseases early.
By getting the
correct health
services,
screenings, and
treatment you
are taking
important steps
toward living a
longer, healthier
life.
Doenges, M.,
Moorhouse, M., &
Murr, A. (2019)
Nurse’s Pocket
Guide (15th
edition, p. 453 –
458) Philadelphia:
F.A Davis
company
Martin, P.,(2020)
4 tonsilitis nursing
care plan
Retrieved from
https://nurseslabs.
com/tonsillitis-
nursing-care-
plans/
Starship, (2018),
tonsillectomy-
management of
post-tonsillectomy
bleeding in CED,
retrieved from
https://www.stars
hip.org.nz/guideli
nes/tonsillectomy-
management-of-
post-
tonsillectomy-
bleed-in-ced/

Nursing Care Plan: Risk For Ineffective Airway Clearance Related To Bleeding From Tonsillectomy Short Term

Uploaded by

Copyright:

Available Formats

Nursing Care Plan: Risk For Ineffective Airway Clearance Related To Bleeding From Tonsillectomy Short Term

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Nursing Care Plan: Risk For Ineffective Airway Clearance Related To Bleeding From Tonsillectomy Short Term

Uploaded by

Copyright:

Available Formats

NURSING CARE PLAN

Cues Nursing Analysis Goals Intervention Rationale Evaluation

You might also like