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Understanding Health Insurance: A Guide to Billing and Reimbursement

Understanding Health Insurance: A Guide to Billing and Reimbursement

14th Edition

ISBN:9781337679480

Author:GREEN

Publisher:GREEN

Chapter7: Cpt Coding

Section: Chapter Questions

Problem 23R

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Priority nursing diagnosis of MENINGITIS DISEASE with NCP(At least 3). PLEASE FOLLOW THE FORMAT OF NCP ON EXAMPLE GIVEN IN THE PICTURE

Sample Nursing Care Plan Format (4 Columns)
Client: Jon Stark
Care Plan by: W. Smith, RN
Date initiated: 12-29-2018
NURSING DIAGNOSIS GOALS & OUTCOMES
Ineffective airway
clearance RT tracheal
bronchial inflammation,
edema formation,
increased sputum
production AEB coughing,
dyspnea, purulent sputum
After 8 hours of nursing
intervention, the patient
will display/maintain patent
airway with breath sounds
clearing; absence of
dyspnea, cyanosis, as
evidenced by keeping a
patent airway and
effectively clearing
secretions.
INTERVENTIONS
1. Assess the rate, rhythm,
and depth of respiration,
chest movement, and use
of accessory muscles.
2. Elevate head of bed,
change position
frequently.
3. Suction as indicated:
frequent coughing,
adventitious breath
sounds, desaturation
related to airway
secretions.
EVALUATION
After 8 hours of nursing
intervention, the patient
was able to maintain
patent airway with breath
sounds clearing AEB
absence of dyspnea,
cyanosis, and effectively
clearing secretions.

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