Nursing care plan | วิชาการ.คอม

Nursing care plan

Nursing care plan คร่าวๆ เน้อ ไป ปรับใช่แก้กันเอาเอง ยังไม่สมบูรณ์ หรอกนะค่ะ

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Esophageal Atresia and Tracheoesophageal Fistula

Nursing Care Plan


Nursing Dx. And

Supporting Data

Goal and Expected


Nursing Intervention and Reasoning


 1. Impaired gas exchange and ineffective airway clearance

Related to :

- Prematurity 33 weeks

- Respiratory distress

- Anemia



Supporting data:

-         HR= 144 – 190 bpm

-         RR= 65 – 74 bpm

-         Mild-Moderate subcostral


-         Intubation mode IMV FiO2  0.6  PIP 13cmH2O PEEP 3 cmH2O  MR  60 bpm

-         CBG ( Oct.9 ,2008 )

      pH                7.327

      pO2                 26.7

      pCO2              55.8

      HCO3             28.6

      BE                     2.2



- Altered gas exchange will be achieved such as.

- O2 sat > 92%

- Skin color is pink

- Normal respiration rate, Heart rate and normal pattern breathing

- Try wean of ventilator

- ABG/CBG normal

- Assess vital signs every two hours and prn. In the presence of  hypoxia, hypotension, tachycardia and tachypnea mat result.

- Assess breathing rate, pattern and depth such as breath sounds, chest expansion, grunting flaring.

- Assess skin color, checking nailbeds and lips for cyanosis.

- Assess lung sounds every two hours. This enables early detection of any deterioration or improvement.

- Use pulse oximetry to continuously monitor oxygenation to have information immediately available to prevent acute hypoxia.

- Assess good ETT position, auscultate for bilateral breath sound s if diminished breath sounds ae present over the left lung field, the ETT is most likely below the carina in the right mainstem bronchus and needs to be pull back.

- Institute mechanical ventilation,with setting as ordered.

- Institute suctioning of airway as needed.

- Hyperoxygenate before and after each suctioning attempt, use approximately 0.10 greater FiO2 than receiving from ventilator.

- Use appropriate suction pressures about 60 – 80 mmHg to prevent further trurma or collapse of airways.


- Good gas exchange, No cyanosis No respiratory distress,

O2 saturation > 92%

Blood gas

normal range.

- Breath sound clear both lung.

CBG ( Oct.10 ,2008 )

- pH            7.432

pO2              31.7

pCO2           40.8

HCO3          26.6

BE                  2.2

- Chest x-ray


Diffuse alveolar infiltration of both lungs is seen. RUL atelectasis is suspected. No pneumothorax is seen.


Nursing Care Plan


Nursing Dx. And

Supporting Data

Goal and Expected


Nursing Intervention and Reasoning


- Anemia

Hct  ( Oct.9 ,2008 )  = 25%

physician give PRC 20 ml IV drip in 2 hours.















- Use sterile saline instillations during suctioning as needed  to help facilitate the removal of tenacious sputum. amount of saline is a few drops to 0.33 ml.

- Notify physician Hct = 25%

- Give PRC 20 ml IV drip in 2 hours. and observe allergic from PRC

- Collect laboratory data as needed such Hct, ABG/CBG.Electrolytes,X-ray.

- Suction clear airway and monitor O2 saturation continuous

- Institute aseptic suctioning of airway

- Institute mechanical ventilation, with setting as ordered.


Repeat Hct = 38.9 %

at ( Oct.10,2008 )









Nursing Dx. And

Supporting Data

Goal and Expected


Nursing Intervention and Reasoning


2. High risk for heart failure

Related To :

- Prematurity



Supporting data:

- Tachycardia

- Echocardiogram

   - Bid ASD = 8 mm

   - Big VSD

   - Big PDA


- Heart    Murmur  

   - SEM grade II




-   Adequate cardiac output will be achieved.

-   Vital signs normal range.

-   I/O balance

-   Urine output > 1cc/Kg/hour


- Maintain appropriate fluid restriction. Fluid restriction is supportive care for the infant with PDA, to prevent cardiovascular overload.

- Continuously monitor cardiac rate, BP,

- Assess pulses in all extremities

- Monitor skin color and capillary refill

- Monitor intake and output hourly

- Monitor changes in CBG ( Acidosis is an early sign of decrease cardiac output.

- Assess perfusion, color, warmth of extremities, presence and quality of peripheral pulses

- Assess vital signs and blood pressure every 2 hours.

- Report tachycardia because this may be indicative of congestive heart failure (CHF).

- Palpate liver edge at right costal margin and mark liver edge daily to detect presence of hepatomegaly; this is a sign of severe CHF.

- Auscultate breath sounds for presence of real.



-HR= 144 – 160 bpm

RR= 60 – 70 bpm

- Trachypnia

- on ventilator

- Chest x-ray


Heart is enlarged. Diffuse alveolar infiltration of both lungs is seen.

- No cyanosis

- To receive fluid in order

- Good  capillary  refill   (< 2 second )

- liver can not palpate



Nursing Care Plan


Nursing Dx. And

Supporting Data

Goal and Expected


Nursing Intervention and Reasoning


3 Risk for obstruction of chest tube

- on chest drain

chest drain work and good drain water / gas

- Provide upright position 20-30 C in order to good drain

- Observe and check chest tube work or not

- Assess with insertion of chest tube to underwater seal and suction

- Observe Bubbling in the water seal unit may indicate an air leak and Observe saliva in chest tube may indicate a anastomotic leakage

- Keep the tubing patent.

- Suction airway as need but do not give deep suction because may trauma at anastomotic is leakage.

- Secure chest tube with tape on chest, on bed

- Examine drainage unit for any blood. Mark fluid level on the outside of the drainage bottle to show fluid loss.

- Frequently of milking for prevent tube obstruction.

ICD is work

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