ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS EXPLANATION

SUBJECTIVE: INEFFECTIVE Tracheobronchial LONG TERM INDEPENDENT: LONG TERM

BREATHING obstruction OUTCOME: OUTCOME
Stated: PATTERN Assess Respiratory ACHIEVED:
“Nahihirapan RELATED TO  After 2 days of respiratory rate and rate and rhythm
akog huminga at TRACHEO- nursing depth by listening to changes are After 2 days of
saka kinakapos Amounts of fluid are intervention, the lung sounds. early warning nursing
BRONCHIAL
ako sa drained from the client will be able signs of intervention, the
OBSTRUCTION
paghinga.” pleural cavity to: impending client will be able
SECONDARY
TO PLEURAL respiratory to:
 Establish a Note muscles
EFFUSION AS difficulties.
normal/effective used for Establish a
OBJECTIVE: EVIDENCED  fluid pressure in breathing(sterno-
respiratory pattern these signify normal/effective
BY DYSPNEA the pleural cavity cleidomastoid,
AEB absence of an increase in respiratory pattern
Dyspnea diaphragmatic) and
 s/s of hypoxia, work of breathing AEB absence of
normal skin color. retractions/flaring of s/s of hypoxia,
Observed
nostrils normal skin color.
physical Atelectasis in the
discomfort affected side of the position client
lung SHORT TERM with proper body
use of This is for good SHORT TERM
OUTCOME: alignment(semi-
accessory  lung excursion
fowler’s position) OUTCOME
muscle noted After 4 hours of and chest
Impaired cardiac ACHIEVED:
nursing expansion
oxygen in use filling/inflamed
intervention, the After 4 hours of
via nasal pleural membranes Ensure that
client will be able nursing
cannula, 2- oxygen delivery
(intensified on intervention, the
3L/min this provides
mucus/secreti inspiration) to: system is applied to adequate client will be able
on the patient, the oxygenation to to:
 verbalize appropriate amount prevent patient
production awareness of of oxygen is from desaturation verbalize
Dyspnea, difficulty in causative factors awareness of
delivered
breathing, altered causative factors
chest excursion, demonstrate pace and
respiratory depth appropriate schedule activities demonstrate
changes coping behaviors providing adequate appropriate
like proper This prevents coping behaviors
rest periods
breathing and dyspnea resulting like proper
coughing Encourage from fatigue breathing and
Reference: Medical
sustained deep coughing
Surgical these promote
breaths by
Nursing:Brunner 11th deep inspiration
emphasizing slow
edition, p.652
inhalation, holding
end inspiration)
Teach client
appropriate deep
breathing and
coughing these facilitate
techniques adequate
clearance of
secretions

COLLABORATIVE:
Administer For
oxygen at lowest management of
concentration underlying
indicated pulmonary
condition and
respiratory
 distress.
Refer the client to --.for proper
a dietician and or counseling and
support groups. intake of caloric
needs.