ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Objective: Ineffective Short term: Independent: Short Term:

Wheezing airway After 30 mins of 1. Monitor respiration 1. To indicative of After 30 mins of Nursing
Dyspnea clearance Nursing Intervention and breath sound. respiratory distress Intervention the patient
PET-CT Scan as the patient will be and/or accumulation of will be able to:
(enlarged evidenced able to: secretion. (Module 15 1. Demonstrated
lymp nodes by Dyspnea Alterations of pulmonary behaviors to
around and 1. Demonstrate function Flashcards ... improved clear
bronchial Wheezing behaviors to (n.d.). Retrieved airway.
tree, improve clear November 27, 2020, from 2. Showed signs of
abdomen, airway. https://quizlet.com/2058 slightly relief
and brachial) 2. Show signs of 74547/module-15- from difficulty
slightly relief alterations-of-pulmonary- of breathing.
Subjective: from function-flash-cards/) 3. Have lowered if
“Minsan difficulty of not normal
nahihirapan breathing. 2. Assist patient in 2. Lower diaphragm, breathing
ako huminga 3. Have lower if semi- fowler’s promoting chest pattern.
at maskit not normal position. expansion, aeration of
dibdib ko” as breathing lung segments, Long Term:
verbalized by pattern. mobilization and After 1 hour of Nursing
the patient. expectoration of Intervention the patient
Long Term: secretions. (MS I Sims - will be able to:
After 1 hour of Scenario 1 & 2 (Pre-
Nursing Intervention Questions) Flashcards ... 1. Relieved from
the patient will be (n.d.). Retrieved breathing
able to: November 27, 2020, from difficulties.
https://quizlet.com/2045 2. Achieved
1. Relieve from 54014/ms-i-sims- comfort and
breathing scenario-1-2-pre- rest.
difficulties. questions-flash-cards/) 3. Improved
2. Achieve airway
comfort and 3. Change position 3. To take advantage of clearance.
rest. every 2 hours. gravity decreasing
3. Improve pressure on the
airway diaphragm and enhance
clearance. ventilation to different
lung segments.
(Lifenurses. (1970,
January 01). Nursing Care
Plans for Acute
Respiratory Distress
Syndrome (ARDS).
Retrieved November 27,
2020, from
http://www.lifenurses.co
m/2009/11/nursing-care-
plans-for-acute.html?
m=1)

4. Encourage deep 4. Helps mobilize secretions.

breathing exercises. (Respiratory Therapy
Zone. (2020, September
24). Airway Clearance
Therapy: Study Guide and
Practice Questions.
Retrieved November 27,
2020, from
https://www.respiratoryt
herapyzone.com/airway-
clearance-therapy/)

5. Perform chest 5. Chest physiotherapy

physiotherapy, if techniques use forces of
needed and also gravity and motion to
instruct patient’s facilitate secretions
significant others in removal. (A778388.
this technique. (n.d.). Chest
Physiotherapy and Airway
 Clearance Devices.
Retrieved November 27,
2020, from
http://www.aetna.com/c
pb/medical/data/1_99/0
067.html)

6. Encourage adequate 6. Prevents fatigue. (Jaret,

rest period. P. (2014, April 01). 9
Ways to Combat Fatigue
and Get Your Energy
Back. Retrieved
November 27, 2020, from
https://www.webmd.com
/balance/features/get-
energy-back)

Dependent:
1. Administer oxygen 1. To correct alveolar
therapy to the and/or tissue hypoxia.
patient as ordered Therefore, any disorder
by the doctor. causing hypoxia is a
potential indication for
oxygen administration.
(Rationale of oxygen
therapy - ResearchGate.
(n.d.). Retrieved
November 27, 2020, from
https://www.researchgat
e.net/publication/289655
126_Rationale_of_oxygen
_therapy)
Collaborative:
1. Instruct and 1. Chest physiotherapy
encourage techniques use forces of
relative to do gravity and motion to
chest facilitate secretions
physiotherapy if removal. (A778388.
needed. (n.d.). Chest
Physiotherapy and Airway
Clearance Devices.
Retrieved November 27,
2020, from
http://www.aetna.com/c
pb/medical/data/1_99/0
067.html)

2. Encourage 2. Helps remove dry

relative to accumulated mucus in
provide nasal the nostrils. (20 effective
care to the ways to get rid of phlegm
patient. and mucus. (n.d.).
Retrieved November 27,
2020, from
https://www.medicalnew
stoday.com/articles/3211
34)