Assessment

Nursing Diagno sis

Planning Long Term Short Term

Intervention Selected Implemented

Rationale

Evaluation

Subjective:
Nahihirapan sya dahil plema. huminga sa

Ineffective airway clearance related increased production of bronchial secretions secondary to fluid shift to extravascular compartment . to

During clients at hospital maintain

the stay the he

Following 8-hr

an

Assess respiratory function, e.g., breath sounds, rate, use muscles and secretion characteri stics and amount. and of

Assessed respiratory rate.

Provides a basis for evaluating adequacy of ventilation

At the end of the shift, the client able display patency airway manifested by: Successful T-piece weaning by achieving the goal of completing 60mins. Clients respiratory rate is of as was to

nursing

intervention, the client will be able to: Achieve successful progressiv e T-piece weaning of (5-15-3045-60 mins) Sustain respiratory rate within normal range: RR12-20 cpm.

as

verbalized by the wife. Objective: On endotrach eal to tube a attached mechanica l ventilator with increasing duration of T-piece weaning clients

will be able to patent airway as evidenced by: Independe nce and ventilatory support Normal respiration as evidenced by from oxygen

Noted chest movement ; use of accessory muscles during respiration .

. Use of

accessory

accessory muscles of respiration may occur in response to ineffective

Auscultate d breath sounds; noted

ventilation . Crackles

Assessment

Nursing Diagno sis

Planning Long Term absence of dyspnea and adventitio us (wet crackles). Normal breathing pattern: RR = 1220 cpm Absence of bronchial secretions Normal chest xray results breath Display decreasing amount of secretions (less than 40cc). Allay restlessness. Short Term

Intervention Selected Implemented

Rationale

Evaluation

(5, 15, 30, 45, mins.) Abnormal breath sounds: wet crackles on (R) and (L) bases. Dyspnea; use muscles for respiration : elevated shoulders. Increase in of accessory lung 60

areas with presence of adventitio us sounds. Document ed respiratory secretions: character and amount of Position patient semihighFowlers position. Assess airway in or Maintained patient on moderate high rest. back sputum.

indicate accumulati on and inability to clear airways. Expectorat ions be different when secretions are thick. very may of secretions

within normal range: RR18 bpm. Secretions decreased in amount from 40 cc to 30 cc collected in an 8-hr shift (Continue assessmen t of respiratory status and suctioning

sounds

Positioning helps maximize

as needed).

Assessment

Nursing Diagno sis

Planning Long Term Short Term

Intervention Selected Implemented

Rationale

Evaluation

respiratory rate: 25 cpm Secretion characteri stics: yellowish in color and 40 ml in amount collected in an 8-hr shift. Chest ray reports haziness on lower hemithora x taken on both xRR-

Allay restlessness

patency.

lung expansion.

Suction as needed when patient ng difficulty of breathing, limiting duration of suction to 15 sec or less. Administer medicatio ns as is experienci

Checked for obstructio ns: accumulati on of secretions. Suctioned patient limited 5-sec duration. to

To maintain adequate airway patency. Duration should limited reduce hazard hypoxia, damage airway mucosa and impair cilia action. of be to Clients restlessne ss and remained calm. was alleviated

Assessment

Nursing Diagno sis

Planning Long Term Short Term

Intervention Selected Implemented

Rationale

Evaluation

Septembe r 7, 2006. Restless Increases lumen size of indicated: Bronchodil ators. nchial tree, thus decreasing resistance to and improving oxygen delivery. airflow the tracheobro

Subjective: Malungkot siya. the As clients verbalized by

Anticipatory grieving related loss to of

During at hospital,

the the he

Following 8-hr

an

Encourage active participati on patient of in

Explained every procedure done to the patient

Active participati on maintains patient

At the end of the shift, the client able to: Have an was

patients stay

nursing

management, the client will be able to:

physiological

will be able to

Assessment

Nursing Diagno sis

Planning Long Term appropriately progress through grieving process evidenced by: Client grieving process progressin g phase phase from 2 3 Cooperate with treatment procedure s. Remain calm. Improve sleeping pattern (uninterru pted sleep of at least as Short Term

Intervention Selected care and Implemented and family. Approache Nurse should visit family frequently and provide physical contact as appropriat e. Allow periods of crying and expression of sadness. Sat with patient and family quietly and active listening as therapeuti used the d the

Rationale

Evaluation

wife. Objective: With episodes of occasional crying Sadness Loss appetite Fatigue General discomfort Uncoopera tive s. with procedure of

well-being secondary to progressive debilitating disease.

Develop awareness which leads c crying. to therapeuti

independe nce and control. Frequent contact helps reduce feelings of isolation and abandonm ent.

improved awareness as manifested by therapeuti c crying (continue providing emotional support). Participate d in treatment

treatment decisions.

family and establishe d rapport the with family.

patients

(feeling) to (dealing) as theorized by Rodebaug h et. al.

This allows for emotional expression .

procedure s. Remained calm: allay restlessne ss.

Assessment

Nursing Diagno sis

Planning Long Term Short Term

Intervention Selected Implemented c communic ation. Encourage Encourage verbalizati on of thoughts/c oncerns and accept expression s sadness, anger, rejection. of d patient and family to express their thoughts and concerns by asking openended questions (e.g. me youre coping.). Tell how

Rationale

Evaluation

Restless Mostly flat affect Changes in sleeping pattern: interrupte d at and awake during daytime. Loss nce: functional level IV. of sleep night fully every hour

Developin g awareness which leads c crying. Cooperate with treatment procedure s. Remain calm. Uninterrup ted sleep at least 6 hours. Patient, 2 hours). to

Patient may in expression of feelings by ding deep often conflicting emotions are normal and experience d others by in the that and understan feel supported Sleeping pattern improved: slept for 2 hours (night shift).

therapeuti

independe

Assessment

Nursing Diagno sis

Planning Long Term Short Term

Intervention Selected Implemented

Rationale

Evaluation

Arrange care to provide for uninterrup ted periods for with his rest, allowing for longer at periods of sleep night when possible. Do as much care as possible without waking the client. for this difficult Maintained a relaxed, calm, nonstimulatin g environme nt. situation. To assist to especially

family, will seek social support and resources appropriat ely.

client establish optimal

sleep/rest pattern.

Assessment

Nursing Diagno sis

Planning Long Term Short Term

Intervention Selected Implemented

Rationale

Evaluation