Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Long Term Short Term Selected Implemented

Subjective:
Ineffective airway During the client’s Following an 8-hr  Assess  Assessed  Provides a At the end of the
“Nahihirapan sya clearance related stay at the hospital nursing respiratory respiratory basis for shift, the client was
huminga dahil sa
to increased he will be able to intervention, the function, e.g., rate. evaluating able to display
plema.” as
production of maintain patent client will be able breath sounds, adequacy of patency of airway
verbalized by the
bronchial airway as to: rate, and use ventilation. as manifested by:
client’s wife.
secretions evidenced by:  Achieve of accessory  Successful T-
secondary to fluid  Independence successful muscles and  Noted chest  Use of piece weaning
Objective:
shift to from oxygen progressive T- secretion movement; accessory by achieving
 On
extravascular and ventilatory piece weaning characteristics use of muscles of the goal of
endotracheal
compartment. support of (5-15-30-45- and amount. accessory respiration completing
tube attached
60 mins) muscles during may occur in 60mins.
to a  Normal
respiration. response to
mechanical respiration as  Sustain  Client’s
ineffective
ventilator with evidenced by respiratory rate respiratory rate
ventilation.
increasing absence of within normal is within
 Auscultated
duration of T- dyspnea and range: RR-12- normal range:
breath sounds;  Crackles
piece weaning adventitious 20 cpm. RR-18 bpm.
noted areas indicate
(5, 15, 30, 45, breath sounds
 Display with presence accumulation  Secretions
60 mins.) (wet crackles).
decreasing of adventitious of secretions decreased in
 Abnormal  Normal amount of sounds. and inability to amount from
breath sounds: breathing secretions clear airways. 40 cc to 30 cc
 Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Long Term Short Term Selected Implemented

wet crackles pattern: RR = (less than  Documented collected in an

on (R) and (L) 12-20 cpm 40cc). respiratory  Expectorations 8-hr shift
lung bases. secretions: may be (Continue
 Absence of  Allay restless-
character and different when assessment of
 Dyspnea; use bronchial ness.
amount of secretions are respiratory
of accessory secretions
sputum. very thick. status and
muscles for
suctioning as
 Normal chest
respiration:
 Position  Maintained needed).
x-ray results
elevated
patient in semi- patient on  Positioning
shoulders.  Client’s
 Allay restless- or high- moderate high helps
restlessness
ness Fowler’s back rest. maximize lung
 Increase in
was alleviated
position. expansion.
respiratory
and remained
rate: RR-25
calm.
 Assess airway  Checked for
cpm
patency. obstructions:  To maintain
 Secretion accumulation adequate
characteristics: of secretions. airway
yellowish in patency.
color and 40  Suction as  Suctioned
ml in amount needed when patient limited  Duration
collected in an patient is to 5-sec should be
8-hr shift. experiencing duration. limited to
 Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Long Term Short Term Selected Implemented

 Chest x-ray reduce hazard

reports of hypoxia,
haziness on damage airway
both lower mucosa and
difficulty of
hemithorax impair cilia
breathing,
taken on action.
limiting
September 7,
duration of
2006.
suction to 15
 Increases
 Restless sec or less.
lumen size of
the
 Administer
tracheobronchi
medications as
al tree, thus
indicated:
decreasing
Bronchodilator
resistance to
s.
airflow and
improving
oxygen
delivery.

Subjective:
Anticipatory During the Following an 8-hr  Encourage  Explained  Active At the end of the
 Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Long Term Short Term Selected Implemented

“Malungkot siya.” grieving related to patient’s stay at nursing active every participation shift, the client was
As verbalized by loss of the hospital, he will management, the participation of procedure maintains able to:
the client’s wife. physiological well- be able to client will be able patient in care done to the patient  Have an
being secondary to appropriately to: and treatment patient and independence improved
Objective:
progressive progress through  Develop decisions. family. and control. awareness as
 With episodes debilitating grieving process awareness manifested by
of occasional disease. as evidenced by: which leads to  Nurse should  Approached  Frequent therapeutic
crying  Client grieving therapeutic visit the family the family and contact helps crying
process crying. frequently and established reduce feelings (continue
 Sadness
progressing provide rapport with of isolation and providing
 Cooperate with
 Loss of from phase 2 physical the patient’s abandonment. emotional
treatment
appetite (feeling) to contact as family. support).
procedures.
phase 3 appropriate.
 Fatigue  Participated in
(dealing) as  This allows for
 Remain calm.
treatment
theorized by  Allow periods  Sat with emotional
 General procedures.
Rodebaugh et.  Improve of crying and patient and expression.
discomfort
al. sleeping expression of family quietly
 Remained
 Uncooperative pattern sadness. and used
calm: allay
 Developing
with (uninterrupted active listening
restlessness.
awareness
procedures. sleep of at as therapeutic
which leads to
least 2 hours). communication  Sleeping
therapeutic
 Restless . pattern
crying.
 Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Long Term Short Term Selected Implemented

 Mostly flat  Cooperate with  Patient may improved: slept

affect treatment  Encourage  Encouraged feel supported for 2 hours
procedures. verbalization of patient and in expression (night shift).
 Changes in
thoughts/conce family to of feelings by
sleeping  Remain calm.
rns and accept express their the
pattern:
expressions of thoughts and understanding
 Uninterrupted
interrupted
sadness, concerns by that deep and
sleep at least 6
sleep every
anger, asking open- often
hours.
hour at night
rejection. ended conflicting
and fully
 Patient, with questions (e.g. emotions are
awake during
his family, will “Tell me how normal and
daytime.
seek social you’re experienced by
support and coping.”). others in this
 Loss of
resources difficult
independence:
appropriately. situation.
functional level
 Arrange care
IV.
to provide for  To assist client
uninterrupted  Maintained a to establish
periods for relaxed, calm, optimal
rest, for non-stimulating sleep/rest
especially environment. pattern.
allowing for
Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Long Term Short Term Selected Implemented

longer periods
of sleep at
night when
possible. Do
as much care
as possible
without waking
the client.