CUES AND NURSING DIAGNOSIS DISERED OUTCOME NURSING RATIONALE EVALUATION

EVIDENCES CRETERIA INTERVENTION

subjective: ineffective airway short term: Patient display
1. Assess 1.Useful in
“maglisod ko ug clearance related to improved
ginhawa excessive, thickened respiratory.rate, evaluating ventilation and
as mucous secretions After 8 hours of adequate
verbalized by the depth. Note use the degree or
nursing interventions oxygenation of
patient. of accessory respiratory distress tissues and
Objective: the patient will: Arterial blood
• Presence of muscles, and chronicity of the
gases (ABGs)
rhonchi. pursed lip breathing, disease process.
• Demonstrate within normal
• Ineffective
improved Inability to speak. range and free
cough.
• V/S taken as ventilation and from symptoms
adequate oxygen. 2.Oxygen delivery of respiratory
follows:
• Arterial blood 2. Elevate head of distress.
may be improved by
gases (ABGs) the
within normal bed, assist patient upright position and
T: 37.2 assume position to
range.
ease work of breathing exercises
P: 79 • No signs of
respiratory breathing. Encourage to decrease airway
R: 24 deep slow or pursed
distress.
lip breathing as collapse, dyspnea
Long term:
BP: 110/80 individually tolerated and work of
or indicated.
After months of 3. Routinely monitor breathing.
skin
nursing and mucous
3.Cyanosis may be
membrane color.
interventions, peripheral in nail
4. Encourage
beds or central in
the patient: expectoration of
lips or earlobes.
sputum; suction
Duskiness and
when
• Ventilation or central cyanosis
indicated
oxygenation is indicate advanced
5.evaluate level of
adequate to meet hypoxemia.
activity tolerance.
self care needs 4.Thick, tenacious,
Provide calm and
copious secretions
quiet environment.
are major source if
ineffective airways.
Deep suctioning
6.Evaluate sleep may be required
patterns, note report when cough is
ineffective for
of difficulties and expectoration of
whether patient feels secretions.
5.during severe or
well rested. acute respiratory
distress, patient may
7. Monitor vital signs be totally unable to
and perform basic self
cardiac rhythm. care activities
Collaborative: because of
8.Administer hypoxemia and
supplemental oxygen dyspnea.
as indicated by ABG 6.Multiple external
results and patients stimuli and presence
tolerance. of dyspnea may
prevent relaxation
and inhibit sleep.
7.Tachycardia,
dysrhythmias, and
changes in blood
pressure can reflect
effect of systemic
hypoxemia on
cardiac function.
8.May correct or
prevent worsening
of hypoxia.
CUES AND EVIDENCES NURSING DIAGNOSIS OBJECTIVE NURSING INTERVENTION RATIONALE
Subjective:  Activity After 10 hours of  Evalua te the  Provide cooperative
 bug.at akong intolerance nursing interventions pt.’s baseline
pamati as vervalize by r/t to generalized the pt. will current activity tolera nce
the pt. body weakness participate willingly in  Adjust  To prevent
as manifested necessary activity and overexertion
Objective: by: activIty reduce intensity of
 Received  Body  Will be task that may cause
malaise noted able to undesired
 Difficulty move her physiological
awake lying moving left arm noted left arm changes
 Facial with ease  Increase exercise
on bed with  Enhance
grimace noted  Learn how to and activity levels
activity
an ongoing  Pallor noted conserve gradu ally
tolerance
 Complains of energy  Teach
IVF of PLRS  Helps mini mize
fatigue  Verbalize methods to
waste of
1 L at 340 relief from fatigue conserve energy
energy
such as sitting than
cc level standing while dressing
 Assist the pt.
regulated  Prevent the pt. from
while doing
injury
at 10 gtts, ADLs
 Give the pt.
infusing  To sustain
info. That provides
the pt.’s motivation
well at right evidence of progress
arm.

 Conscious/c
oherent
 Body
malaise
noted
 Difficulty
moving left
arm noted
 Facial
grimace
noted
 Pallor noted
 Complains
of fatigue

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