Date Assessment Nursing Expected Nursing Rationale Evaluation
Data Diagnosis Outcomes Interventions Criteria
08/01/2018 Pattern of Ineffective Short Term: Determine To identify the Short Elimination Airway After 5-10 presence precipitating factors Term: Clearance minutes of factors/ After 5-10 related to nursing physical minutes of excessive intervention, conditions nursing tenacious the client’s that would intervention, mucus airway will cause the client’s secretion as be cleared breathing airway was evidenced from mucus impairments cleared from by or secretions Auscultate To evaluate presence/ mucus and ineffective will be chest character of breath the breathing minimized & sounds/secretion secretions pattern will establish Evaluate It indicates possible has been a normal presence of obstruction minimized respiratory secretions & will pattern. Elevate HOB To promote physiological/ established a psychological ease of normal Decreased or maximal inspiration respiratory absence of Monitor To verify pattern. coarse pulse maintenance/improvement crackles will oximetry in O2 saturation Decreased or also be noted. To clear secretions absence of Suction mechanically. coarse airway every crackles was 1 hour or as also noted upon needed. So that in case of transfer auscultation. Enteral of fluids in the airway, it Feeding of 8 will not further aggravate Long Term: AM and 12 into the accumulated After 1 week PM based on secretions & the patient Long Term: or more, the dietician will able to breathe patient will orders & spontaneously during After two (2) be able to being assured feeding. days and tolerate that the ahead, the weaning and client’s patient was be able to respiration is able to breathe free or have dependently dependently fewer with oxygen. with oxygen. secretions before feeding. To increase Fluid intake Add 20-30 & helps to decrease the ml of water consistency of mucus. before and after the feeding. For baseline data Monitor vital signs every hour especially To manage patient if ever RR. inconvenience or Refer the alteration happen. patient and consult with the Respiratory therapist in any alteration in patient’s ABG and mechanical To provide the baseline ventilation. and assess patient’s progress on her condition. Monitor laboratory results
Police Dogs From Albania As Indicators of Exposure Risk To Toxoplasma Gondii, Neospora Caninum and Vector-Borne Pathogens of Zoonotic and Veterinary Concern