Assessment Nursing Planning Intervention Rationale Evaluation
Diagno
sis Long Term Short Term Selected Implemented
Subjective: Ineffective During the Following an ♦ Assess ♦ Assessed ♦ Provides a At the end of
“Nahihirapan airway client’s stay 8-hr nursing the shift, the
clearance at the intervention, respiratory respiratory basis for client was
sya huminga
dahil sa related to hospital he the client will function, rate. evaluating able to
plema.” as increased will be able to be able to: display
verbalized by production of maintain e.g., adequacy patency of
Achieve
the client’s bronchial patent airway breath of airway as
wife. secretions as evidenced successful manifested
secondary to by: sounds, ♦ Noted ventilation by:
progressiv
Objective: fluid shift to Independe rate, and chest . Successful
extravascular e T-piece
On nce from use of movement T-piece
compartment weaning of
endotrach . accessory ♦ Use of
oxygen ; use of weaning
(5-15-30-
eal tube and muscles accessory by
45-60 accessory
attached and muscles of
ventilatory muscles achieving
mins)
to a support secretion respiration the goal of
during
mechanica characteri may occur
Sustain respiration completing
l ventilator Normal stics and in 60mins.
respiratory .
with respiration amount. response
rate within
increasing as to Client’s
normal
♦ Auscultate ineffective
duration of evidenced respiratory
range: RR-
d breath ventilation
T-piece by rate is
12-20
sounds; .
weaning absence of within
cpm.
noted
(5, 15, 30, dyspnea normal
areas with ♦ Crackles
45, 60 and Display range: RR-
presence indicate
mins.) adventitio decreasing
Assessment Nursing Planning Intervention Rationale Evaluation
Diagno
sis Long Term Short Term Selected Implemented
Abnormal us breath amount of of accumulati 18 bpm.
breath sounds secretions adventitio on of
(wet (less than us sounds. secretions Secretions
sounds:
crackles). 40cc). and decreased
wet
♦ Document inability to in amount
crackles
Normal Allay ed clear from 40 cc
on (R) and
breathing restless- respiratory airways. to 30 cc
(L) lung ♦ Position
pattern: ness. secretions: collected
bases. patient in
RR = 12- character ♦ Expectorat in an 8-hr
semi- or
Dyspnea; 20 cpm and ions may shift
high-
use of amount of be (Continue
Fowler’s
Absence of sputum. different assessmen
accessory position.
bronchial when t of
muscles
secretions ♦ Maintained secretions
for ♦ Assess respiratory
patient on are very
respiration airway status and
Normal moderate
: elevated patency. thick. suctioning
chest x- high back
shoulders. as
ray results rest.
needed).
♦ Positioning
Increase in
Allay ♦ Suction as helps
respiratory Client’s
restless- needed ♦ Checked maximize
rate: RR- restlessne
ness when for lung
25 cpm ss was
patient is obstructio expansion.
alleviated
Assessment Nursing Planning Intervention Rationale Evaluation
Diagno
sis Long Term Short Term Selected Implemented
Secretion experienci ns: and
characteri ng accumulati remained
♦ To
stics: difficulty on of calm.
maintain
yellowish of secretions.
adequate
in color breathing,
airway
limiting ♦ Suctioned
and 40 ml
patency.
duration of patient
in amount
suction to limited to
collected ♦ Duration
15 sec or 5-sec
in an 8-hr should be
less. duration.
shift. limited to
reduce
Chest x- ♦ Administer
hazard of
ray medicatio
hypoxia,
reports ns as
damage
haziness indicated:
airway
on both Bronchodil
mucosa
lower ators.
and impair
hemithora
cilia
x taken on
action.
Septembe
r 7, 2006.
♦ Increases
lumen size
Assessment Nursing Planning Intervention Rationale Evaluation
Diagno
sis Long Term Short Term Selected Implemented
Restless of the
tracheobro
nchial
tree, thus
decreasing
resistance
to airflow
and
improving
oxygen
delivery.
Subjective: Anticipatory During the Following an ♦ Encourage ♦ Explained ♦ Active At the end of
“Malungkot grieving patient’s stay 8-hr nursing the shift, the
related to at the management, active every participati client was
siya.” As
verbalized by loss of hospital, he the client will participati procedure on able to:
the client’s physiological will be able to be able to: Have an
well-being appropriately on of done to maintains
wife. Develop
secondary to progress improved
patient in the patient patient
progressive through awareness
Objective: awareness
care and and independe
debilitating grieving which
With disease. process as as
treatment family. nce and
evidenced leads to
episodes manifested
decisions. control.
by: therapeuti
of ♦ Approache by
Client
occasional ♦ Nurse d the ♦ Frequent therapeuti
Assessment Nursing Planning Intervention Rationale Evaluation
Diagno
sis Long Term Short Term Selected Implemented
crying grieving c crying. should family and contact c crying
process visit the establishe helps (continue
Sadness progressin Cooperate family d rapport reduce providing
g from with frequently with the feelings of emotional
Loss of treatment
phase 2 and patient’s isolation support).
appetite procedure
(feeling) to provide family. and
phase 3 s. physical abandonm Participate
Fatigue
(dealing) contact as ent. d in
Remain ♦ Sat with
as appropriat treatment
General
calm. patient
theorized e. procedure
discomfort
and family ♦ This allows
by s.
Improve quietly for
Uncoopera Rodebaug ♦ Allow
sleeping and used emotional Remained
tive with h et. al. periods of
pattern active expression calm: allay
procedure crying and
(uninterru listening . restlessne
s. Developin expression
pted sleep as ss.
g of
of at least therapeuti
Restless awareness sadness.
2 hours). c Sleeping
which
Mostly flat communic pattern
leads to
affect ation. ♦ Patient improved:
therapeuti
may feel slept for 2
c crying.
Changes ♦ Encourage ♦ Encourage hours
supported
in sleeping verbalizati d patient (night
Cooperate in
Assessment Nursing Planning Intervention Rationale Evaluation
Diagno
sis Long Term Short Term Selected Implemented
pattern: with on of and family expression shift).
interrupte treatment thoughts/c to express of feelings
d sleep procedure oncerns their by the
every hour s. and accept thoughts understan
at night expression and ding that
and fully Remain s of concerns deep and
awake calm. sadness, by asking often
during anger, open- conflicting
Uninterrup
daytime. rejection. ended emotions
ted sleep
questions are normal
Loss of at least 6
(e.g. “Tell and
independe hours.
me how experience
nce: you’re d by
Patient,
functional coping.”). others in
with his ♦ Arrange
level IV. this
family, will care to
seek social provide for difficult
support uninterrup situation.
♦ Maintained
and ted
a relaxed, ♦ To assist
resources periods for
calm, non- client to
appropriat rest, for
stimulatin establish
ely. especially
g optimal
allowing
environme sleep/rest
Assessment Nursing Planning Intervention Rationale Evaluation
Diagno
sis Long Term Short Term Selected Implemented
for longer
periods of
sleep at
night
when
possible.
Do as nt. pattern.
much care
as possible
without
waking the
client.
