Professional Documents
Culture Documents
DIAGNOSES OUTCOME
Ineffective airway To maintain a Elevate the head of To prevent Maintains clear
clearance related patent airway and the bed 30 aspiration. airway and
to altered LOC ensure ventilation degrees. demonstrates
appropriate breath
Position the patient To promote sounds.
in a lateral or semi drainage of
prone position. secretions.
Suctioning should
also be done. To remove
secretions.
Chest
physiotherapy and
postural drainage To promote
may be initiated. pulmonary hygiene.
Auscultate the
chest every 8 To detect
hours. adventitious breath
sounds or absence
of breath sounds.
Risk of injury To protect the Ensure that side To prevent Experiences no
related to patient from injury rails are padded occurrence of injury injuries.
decreased LOC and kept in raised due to fall.
position for the day
and three nights
Use of splints or
foam boots. To help prevent
foot drop and
eliminates the
pressure of bedding
Use of trochanter on the toes.
rolls.
To support the hip
joints and keep the
legs in proper
Fluidized or low-air- alignment.
loss beds may be
use. To decrease
pressure on bony
prominences.
Impaired tissue To preserve corneal Eyes should be To remove debris Has no corneal
integrity of cornea integrity. cleansed with and discharges. irritation
related to cotton balls with
diminished or sterile normal
absent corneal saline To prevent dryness.
reflex
Instill artificial tears
every 2 hours if
prescribed. To avoid contact
with the cornea.
If cold compress is
prescribed, care
must be exerted.
Ineffective To maintain body Environment can To promote a Attains or maintains
thermoregulation temperature be adjusted, normal body thermoregulation
related to damage depending on the temperature.
to hypothalamic patient’s condition.
center
Remove all bedding To lessen the heat.
over the patient.