What could be 1 nursing diagnosis, 1 outcome/smart goal

What could be 1 nursing diagnosis, 1 outcome/smart goal, 5 interventions, 5 rationales, 5 evaluations for a patient who is a 66-year-old who is diagnosed with Edema/Anasarca? The patient is at risk of ineffective airway clearance RIT neurological dysfunction evidenced by the patient's CVA dysphagia present. History of present illness: The patient was brought to the hospital for generalized edema. Past medical and surgical history: Hypothyroidism, rheumatoid arthritis."

For a 66-year-old patient with edema/anasarca and a risk of ineffective airway clearance due to neurological dysfunction, here’s a detailed nursing care plan:For a 66-years old patient with edema/anasarca as well as the risk of ineffective airway clearance: neurological dysfunction here is the detailed nursing care plan.

 Nursing Diagnosis:

 function as referring to the capability to clean the respiratory tract in the case of edema/anasarca and neurological deficit in view of CVA and dysphagia relevant to IAC.

 SMART Goal:

 At the end of shift the patient’s respiratory rate will be within the normal range of 12-20 breaths per minute; findings will be normal there will be no crackles or wheezing and breath sounds will be clear and enhanced.

 Interventions:

 Monitor Respiratory Status:

 Rationale: Examination signs of the patient in relation to respiratory rate, oxygen saturation and noises heard over the lungs are made in an attempt to identify the later signs of poor airway clearance.

 Evaluation: Include an evaluation of the patient’s respiratory rate and O2 saturation level assessment as to if it is normal range or not and his/her lung sounds that may be more or less audible compared to previous assessment.

 Elevate Head of Bed:

 Rationale: Lifting the upper end also helps to reduce oedema in the chest area and aids to fully extend the lungs so that proper coughing is achieved.

 Evaluation: Therefore, notice whether the patient complains of shortness of breath and compare the results to the extent of respiratory movements.

 Administer Diuretics as Prescribed:

 Rationale: Diuretics are useful in increasing the urine output and decreasing the edema as well as over all airway clearance.

 Evaluation: Examine the patient’s weights, intake output and presence or absence of peripheral oedema if diuretics are to be used.

 Implement Swallowing Precautions:

 Rationale: Because dysphagia the texture of food and liquids need to be changed in a way that the patient will not aspirations, and the airway must also be protected.

 Evaluation: Determine the patient’s ability to handle and swallow food and liquids without chocking or aspiration reviews the texture and change to foods and liquids if difficult.

 Encourage and Assist with Deep Breathing and Coughing Exercises:Promote and Supporting Techniques of Deep Breathing and Coughing for Client:

 Rationale: Techniques such as, breathing exercises and coughing exercises help in the process aeration of secretions, exercise of lung capacity and removal of any blockage.

 Evaluation: Ask the patient about how independent, cooperative and performant the patient is with the exercises as well as get the fact about the respiratory sounds and secretion clearance.

 Rationales:

 Monitoring Respiratory Status: It has the advantage of helping to determine presence of the acute respiratory distress at a time when it can be managed.

 Elevating Head of Bed: It offloads a load that is put on the lungs when one is making efforts to breathe better air.

 Administering Diuretics: Prevents pressure on the respiratory system by preventing oedema and fights the development of some of the fluids which lead to oedema.

 Implementing Swallowing Precautions: Prevents aspiration, and other similar respiratory problems.

 Encouraging Breathing Exercises: It assists in experctoration and also improves on the capabilities of the lungs.

 Evaluations:

 Respiratory Rate and Oxygen Saturation: Ensure that these are within acceptable level of parameters which will imply proper clearance of the airways.

 Lung Sounds: Look particularly for the absence of lung sounds and to hear for increased and clear lung sounds instead of abnormal ones.

 Fluid Status: Oversee a little amount of oedema and satisfactory amount of diuresis.

 Swallowing Safety: Assess and document safety of swallowing and alter the interventions if and as required.

 Effectiveness of Breathing Exercises: Monitoring of variation in degree of disability evidenced by patient’s capability to perform exercise and other respiratory tests.

 This presents the current care plan on the patient and its particular emphasis on the problem of impaired airway clearance consequent upon edema and neurological compromise and identifies ways in which the patient might be helped.