JENNY DELOS SANTOS

BSN- Blk-3

ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS

Subjective: Ineffective After 8 hours of -Asses respiratory note quality, -both rapid swallow breathing Goal met.
airway clearance nursing rate, pattern, depth, and breathing pattern and hypoventilation affect After 8 hours of
related to intervention the effort.. gas exchange nursing
“Ubo ako ng ubo retained patients will be intervention the
as verbalized by secretions able to maintain patient was able to
the patients. airway patency  -with initial hypoxia and maintain airway
and clear hypercapnia blood pressure heart patency and clear
secretions readily -monitor vital sign rate and respiratory all rise as secretion readily.
the hypoxia or hypercapnia
Objective: become more severe BP may
- Restlessness drop, heart rate tends to continue
- cough to be rapid with arrhythmias ,and
-with left side respiratory failure may ensure
CTT connected to with the patients unable to
thorabottle maintain the rapid respiratory
rate.

- Vital Signs -maintain oxygen administration -this provides for adequate

taken as: device as ordered. Attempting to oxygenation
(As of March 2, maintain oxygen saturation at 90%  
2011 8pm) or greater.

Temp – 36.9 -assess patient ability to cough -retained secretions impair gas
PR- 105 bpm effectively to clear secretions. exchange
(tachycardia) Note quantity, color, and
RR- 26cpm consistency of sputum.
BP-110/80
-position with proper body -this promotes lung expansion
alignment for optimal and improves air exchange
Respiratory excursion

-Teach patient appropriate deep -these facilitate adequate air

breathing and coughing technique exchange and secretion clearace