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| AI generated |
**Comprehensive Nursing Care Plan for Common Cold and Cough
Patient Information:
- Name: [Insert Name]
- Age: [Insert Age]
- Gender: [Insert Gender]
- Date: [Insert Date]
- Nurse: [Insert Name]
Assessment
Subjective Data:
- Patient reports nasal congestion, sore throat, and dry or productive cough.
- Complains of headache, mild body aches, and fatigue.
- States difficulty sleeping due to persistent coughing.
Objective Data:
- Vital signs: [Insert Values, e.g., temperature, respiratory rate, etc.]
- Frequent coughing observed during assessment.
- Nasal discharge and slight redness in the throat.
- Lung auscultation reveals clear or slightly coarse breath sounds.
Nursing Diagnoses
- Ineffective Airway Clearance related to mucus accumulation and nasal congestion as evidenced by coughing and nasal discharge.
- Disturbed Sleep Pattern related to persistent coughing and nasal congestion as evidenced by patient complaints of difficulty sleeping.
- Fatigue related to increased energy demands from illness and interrupted sleep as evidenced by patient reports of tiredness.
- Risk for Infection Spread related to coughing and sneezing as evidenced by potential exposure to others.
Goals and Outcomes
Short-Term Goals:
- Patient will demonstrate effective airway clearance as evidenced by reduced coughing and nasal congestion within 24 hours.
- Patient will report improved sleep quality within 48 hours.
Long-Term Goals:
- Patient will verbalize understanding of preventive measures to avoid spreading infection by discharge.
- Patient will exhibit increased energy levels and ability to perform daily activities within one week.
Interventions and Rationales
1. Ineffective Airway Clearance:
- Intervention: Encourage increased fluid intake (e.g., water, herbal teas) if not contraindicated.
- Rationale: Helps loosen mucus and facilitates easier airway clearance.
- Intervention: Teach the patient to use steam inhalation or a humidifier.
- Rationale: Moistens airways and reduces nasal congestion.
- Intervention: Administer prescribed expectorants or decongestants as needed.
- Rationale: Helps clear mucus and alleviate congestion.
2. Disturbed Sleep Pattern:
- Intervention: Encourage the patient to sleep with their head elevated using extra pillows.
- Rationale: Reduces postnasal drip and coughing during the night.
- Intervention: Suggest warm fluids, such as honey and lemon tea, before bedtime.
- Rationale: Soothes the throat and reduces nighttime coughing.
- Intervention: Limit environmental stimuli (e.g., reduce noise and dim lights) at bedtime.
- Rationale: Promotes a calming environment conducive to sleep.
3. Fatigue:
- Intervention: Encourage the patient to rest and avoid strenuous activities.
- Rationale: Conserves energy for recovery.
- Intervention: Provide guidance on balanced nutrition with easily digestible, nutrient-rich foods.
- Rationale: Supports immune function and energy levels.
4. Risk for Infection Spread:
- Intervention: Educate the patient on proper hand hygiene and the use of tissues when coughing or sneezing.
- Rationale: Reduces the risk of transmitting infection to others.
- Intervention: Advise the patient to avoid close contact with others until symptoms improve.
- Rationale: Minimizes the spread of pathogens.
Evaluation
- Patient demonstrates effective airway clearance with reduced coughing and nasal congestion.
- Patient reports improved sleep quality and exhibits reduced fatigue.
- Patient verbalizes understanding of infection prevention measures.
- Patient resumes daily activities with minimal discomfort.
Education and Discharge Planning:
- Teach the patient to recognize signs of worsening symptoms, such as high fever or difficulty breathing, and to seek medical attention promptly.
- Emphasize the importance of hydration, balanced nutrition, and rest during recovery.
- Provide guidance on over-the-counter remedies, such as saline nasal sprays or throat lozenges, as appropriate.
- Encourage adherence to follow-up appointments if symptoms persist or worsen.
**
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