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ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:

“Ilang araw na syang
inuubo at nahihirapang
huminga,” as verbalized
by the relative of the
patient.

Objective:
 O2 sat: 80%
 With O2 at
2LPM via nasal
cannula
 Respirations:
24breaths/min
 Chronically bed
ridden
 81 y/o
 Skin is pale and
cool to touch
 Use of accessory
muscles when
breathing
 Inspiratory
crackles with
diminished
breath sounds
when
auscultated
 Thick yellow
sputum is
present during
suctioning









Ineffective airway
clearance related to thick
sputum secondary to
pneumonia as evidenced
by adventitious
breath sounds and thick
yellow sputum.

Pneumonia is an
inflammation of the lung
parenchyma, associated
with alveolar edema and
congestion that impair
gas exchange.


Short Term:
After 8 hours of nursing
interventions, the patient
will be able to
expectorate/clear
secretions readily.

Long Term:
After 1 week of nursing
interventions, the patient
will be able to maintain
airway patency by
showing:

a. Normal breath
sounds when
auscultated
b. Respiratory rate
of 16-20
breaths/min
c. Not using
accessory
muscles when
breathing

Monitor rate, rhythm,
depth, and effort of
respirations.

Note chest movements,
watch for symmetry, use
of accessory
muscles, and
supraclavicular and
intercostal muscle
retractions.

Elevate head of the
bed/change position
every 2hours and prn





Promote systemic fluid
hydration, as
appropriate.



Oral suction prn.



Auscultate lung sounds
after treatments to note
results.

Institute respiratory
therapy treatments (e.g.,
nebulizer, expectorant,
bronchodilators) as
needed.



Provides a basis for
evaluating adequacy of
ventilation.

Presence of nasal flaring
and use of accessory
muscles of respirations
may occur in response to
ineffective ventilation.



To take advantage of
gravity decreasing
pressure on the
diaphragm and
enhancing drainage
of/ventilation to different
lung segments.

Adequate fluid intake
enhances liquefaction of
pulmonary secretions
and facilitates
expectoration of mucus.

To clear out secretions
when it blocks the
airway.

Assists in evaluating
prescribed treatments
and client outcomes.

A variety of respiratory
therapy treatments may
be used to open
constricted airways and
liquefy secretions.


Short Term:
After 8 hours of nursing
interventions, the patient
was able to
expectorate/clear
secretions readily.

Long Term:
After 1 week of nursing
interventions, the patient
was able to maintain
airway patency by
showing:

a. Normal breath
sounds when
auscultated
b. Respiratory rate
of 16-20
breaths/min
c. Not using
accessory
muscles when
breathing
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:

Patient’s relative stated,
“lalo syang nanghina
nung magkaubo.”


Objective:
 O2 sat: 80%
 With O2 at
2LPM via nasal
cannula
 Respirations:
24breaths/min
 Chronically bed
ridden
 81 y/o
 Skin is pale and
cool to touch
 PEG
 Iron supplement
medication



Activity intolerance
related to exhaustion
associated with
interruption in usual
sleep pattern because of
discomfort, excessive
coughing, and dyspnea as
evidenced by verbal
reports.

Definition: Insufficient
physiological or
psychological energy to
endure or complete
required or desired daily
activities



Short Term:
After 8 hours of nursing
interventions, the patient
will be able to report a
measurable increase in
tolerance to activity with
absence of dyspnea and
excessive fatigue, and
vital signs within
patient’s acceptable
range.

Long Term:
After 1 week of nursing
interventions, the patient
will be able demonstrate
a measurable increase in
tolerance to activity with
absence of dyspnea and
excessive fatigue, and
vital signs within
patient’s acceptable
range.



Evaluate patient’s
response to activity. Note
reports of dyspnea,
increased weakness/
fatigue, and changes in
vital signs during and
after activities.

Provide a quiet
environment and limit
visitors.

Explain importance of
rest in treatment plan
and necessity for
balancing activities with
rest.








Assist patient to assume
comfortable position for
rest/ sleep.




Assist with self-care
activities as necessary.
Provide for progressive
increase in activities
during recovery phase
and demand.



Establishes patient’s
capabilities/needs and
facilitates choice of
interventions.




Reduces stress and
excess stimulation,
promoting rest.

Bed rest is maintained
during acute phase to
decrease metabolic
demands, thus
conserving energy for
healing. Activity
restrictions thereafter
are determined by
individual patient
response to activity and
resolution of respiratory
insufficiency.

Patient may be
comfortable with head of
bed elevated, sleeping in
a chair, or leaning
forward on over bed
table with pillow support.

Minimizes exhaustion
and helps balance oxygen
supply and demand.






Short Term:
After 8 hours of nursing
interventions, the patient
was able to report a
measurable increase in
tolerance to activity with
absence of dyspnea and
excessive fatigue, and
vital signs within
patient’s acceptable
range.

Long Term:
After 1 week of nursing
interventions, the patient
was able demonstrate a
measurable increase in
tolerance to activity with
absence of dyspnea and
excessive fatigue, and
vital signs within
patient’s acceptable
range.