ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective data:
nahihirapan siyang
huminga, as verbalized
by the S.O.
Objective data:
crackles
RR: 3 cpm
use !" access!ry
muscles
#ne""ective air$ay
clearance related t! stasis
!" secreti!ns in the
br!nchi.
%t the end !" & h!ur, the
patient $ill be able t!
maintain air$ay p!tency
and e'pect!rate(clear
secreti!ns readily.
)levated head !" the
bed( change p!siti!n
every * h!urs.
+er"!rmed back
tapping
)nc!uraged increase
"luid intake via ,-.
+er"!rmed chest
physi!therapy.
+r!vide supplemental
humidi"icati!n
/nebulizer0.
1!nit!red vital signs.
.! take advantage !"
gravity decreasing
pressure !n the
diaphragm.
.! m!bilize
secreti!ns.
.! help li2ue"y
secreti!ns.
.! l!!sen secreti!ns.
.! ascertain status and
n!te pr!gress.
.! assess changes and
n!te c!mplicati!ns.
-!al met. %t the end !" &
h!ur, the patient $as able
t! maintain air$ay
p!tency and
e'pect!rate(clear
secreti!ns readily.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective data:
hindi niya kayang
igala$ ang kanang
bahagi ng kata$an niya
kahit alalayan pa namin
siya, as verbalized by
the S.O.
Objective data:
limited range !"
m!ti!n
decreased
reacti!n time
reluctance t!
attempt
m!vement
"uncti!nal level
classi"icati!n3
#mpaired physical
m!bility related t!
muscul!skeletal
impairment as evidence
by inability t! m!ve
purp!se"ully $ithin
physical envir!nment.
%t the end !" the shi"t,
the patient $ill be able t!
increase strength !"
a""ected and(!r
c!mpensat!ry b!dy
parts.
)nc!urage and
"acilitate early
ambulati!n and !ther
%45 $hen p!ssible.
%ssist $ith each initial
change: dangling, sitting
in chair, and ambulati!n.
6eep side rails up and
bed in l!$ p!siti!n.
1aintain limbs in
"uncti!nal alignment.
Supp!rt "eet in
d!rsi"le'ed p!siti!n and
use bed cradle.
+er"!rm passive(active
assistive RO1 e'ercises
t! all e'tremities.
.urn patient t! pr!ne
!r semipr!ne p!siti!n
!nce daily unless
c!ntraindicated.
.! pr!m!te !ptimal
range !" m!ti!n.
.! pr!m!te sa"e
envir!nment.
.! prevent "!!tdr!p
and(!r e'cessive plantar
"le'i!n !r tightness.
.! pr!m!te increased
ven!us return, prevent
sti""ness, and maintain
muscle strength and
endurance.
.! drain br!nchial
tree.
)nc!urage c!ughing
and deep breathing
e'ercises. 7se sucti!n as
needed.
)nc!urage li2uid
intake !" *88893888
ml(day unless
c!ntraindicated.
.! prevent build up !"
secreti!ns.
.! !ptimize hydrati!n
status and prevent
hardening !" st!!l.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective data:
nagigising siya minsan
dahil sa phelgm, as
verbalized by the patient.
Objective data:
4ark circles under
eyes
Restlessness
)'pressi!nless "ace
:re2uent ya$ning
4isturbed sleep pattern
related t! statis !"
secreti!ns.
%t the end !" the shi"t,
the patient $ill be able t!
achieve !ptimal am!unts
!" sleep as evidence by
rested appearance,
verbalizati!n !" "eeling
rested, and impr!vement
in sleep pattern.
)levated head !" the
bed( change p!siti!n
every * h!urs.
Sucti!n secreti!n prn
+r!vide nursing aid:
back rub bedtime care,
pain relie", c!m"!rtable
p!siti!n, and rela'ati!n
techni2ue.
%ttempt t! all!$ "!r
sleep cycles !" at least
;8mins.
4isc!urage pattern !"
daytime naps unless
necessary !r part !" usual
pattern.
5imit "luids be"!re
bedtime.
.! take advantage !"
gravity decreasing
pressure !n the
diaphragm.
.! rem!ve
accumulated secreti!ns
.! pr!m!te rest and
rela'ati!n.
.! pr!m!te
c!mpleti!n !" !ne
c!mplete cycle and
c!mpleti!n !" an entire
cycle is necessary t!
bene"it "r!m sleep.
,apping can disrupt
n!rmal sleep pattern.
.! reduce need "!r
v!iding during night.
-!al met. %t the end !"
the shi"t the patient $as
able t! achieved !ptimal
am!unts !" sleep as
evidence by rested
appearance and
verbalizati!n !" "eeling
rested.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
<igh risk "!r impaired
skin integrity related t!
imm!bility.
%t the end !" the shi"t,
the patient $ill be able t!
dem!nstrate behavi!rs t!
prevent skin breakd!$n.
1assage b!ny
pr!minences gently.
=hange p!siti!n in bed
every * h!urs.
6eep bedcl!thes dry,
use n!nirritating
materials, and keep bed
"ree !" $rinkles, crumbs,
and s! "!rth.
+r!vide pr!tecti!n by
use !" pads, pill!$s,
"!am mattress and s!
"!rth.
Observe "!r
reddened(blanched areas
and institute treatment
immediately.
6eep nails sh!rt.
)nc!urage increase
.! maintain skin
integrity at !ptimal level.
.! pr!vide circulati!n.
.! retain skin integrity
at !ptimal level.
.! increase circulati!n
and alter(eliminate
e'cessive tissue pressure.
.! reduce likelih!!d
!" pr!gressi!n t! skin
breakd!$n.
.! reduce risk !"
dermal injury.
.! maintain skin
-!al met. %t the end !"
the shi"t the patient $as
able t! dem!nstrate
behavi!rs t! av!id skin
breakd!$n.
"luid intake per ,-.. turg!r.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
<igh risk "!r aspirati!n
r(t depressed gag re"le'.
%t the end !" the shi"t,
the patient $ill be able t!
e'perience n! aspirati!n
as evidence by n!iseless
aspirati!ns and clear
breath s!unds.
6eep sucti!n setup
available and use as
needed.
+!siti!n client !n side.
)valuate client t!
highest !r best p!siti!n
"!r eating and drinking
during tube "eeding.
%scertain that "eeding
tube is in c!rrect
p!siti!n.
=heck residuals pri!r
t! "eeding.
.! maintain a patent
clear air$ay.
.! pr!vide air$ay
pr!tecti!n.
.! "acilitate passage
!" st!mach c!ntents int!
the du!denum.
.! prevent delivery !"
"!!d int! the air$ay.
.! prevent
!ver"eeding and re"lu'
emesis.
-!al met. %t the end !"
the shi"t the patient $as
able t! e'perience n!
aspirati!n as evidence by
clear breath s!unds.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
<igh risk "!r
Sens!ry(+erceptual
%lterati!ns /.actile0 r(t
p!st str!ke
%t the end !" the shi"t,
the patient>s skin $ill
remain "ree !" injuries,
including pressure ulcers.
+er"!rm regular skin
inspecti!ns.
+r!vide tactile
stimulati!n t! a""ected
limbs using r!ugh cl!th
!r hand and instruct S.O.
in meth!ds used.
)'plain h!$ stimulus
might "eel
.each patient t! check
temperature !" $ater
$ith una""ected side
be"!re using $ater.
Regularly m!ve
a""ected limbs.
)nhance envir!nment
.! assess c!nditi!n !"
underlying tissues.
.! assess ability t!
sense stimuli.
.! pr!vide patient
$ith the right
descripti!n.
.hermal screening
.! "acilitate
circulati!n !n the
a""ected limbs.
.! av!id "urther
-!al partially met. %t the
end !" the shi"t the
patient dem!nstrate
understanding !n
measures t! stimulate
sens!ry percepti!n.
"!r !ptimum sa"ety. c!mplicati!ns and
injuries.