ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTIONS
Subjective: Acute Pain R/T Disruption Short-term Goal: Independent: Goal Met
“I think a have a bug of Skin, Tissue, And After 1 hour of nursing  Administer analgesics as  To maintain Short-term Goal:
in my stomach I can’t Muscle Integrity Secondary interventions, the patient prescribed, to maximum “acceptable” level of After 1 hour of nursing
stop throwing up” as to Surgical Incision will report that the pain is dosage as needed pain. Notify physician interventions, the
verbalized by the relieved or controlled. if regimen is inadequate patient reported that the
patient. to meet pain control pain is relieved or
Long-term Goal: goal. Combinations of controlled.
After 8 hours of nursing medications may be
Objective: intervention, the patient used on prescribed Long-term Goal:
 Skinny will verbalize sense of intervals. After 8 hours of nursing
control of response to Dependent: intervention, the patient
 Pain scale of 8 out acute situation and  Obtain client’s  In order to fully verbalized sense of
of 10 positive outlook for the assessment of pain to understand client’s pain control of response to
future. include location, symptoms. Note: acute situation and
 Facial grimace characteristics, onset, experts agree that positive outlook for the
duration, frequency, attempts should always future.
 RR: 36 cpm quality, intensity. Identify be made to obtain self-
precipitating or reports of pain. When
 PR: 142 bpm aggravating and relieving that is not possible,
factors. credible information
 BP: 164/100 can be received from
another person who
knows the client.
 Pale
 Perform pain assessment  To demonstrate
 Sweating
each time pain occurs. improvement in status
Document and investigate or to identify worsening
changes from previous of underlying
reports and evaluate condition/developing
results of pain complications.
interventions.
 Observe nonverbal cues  Observations may not
and pain behaviors and be congruent with
other objective Defining verbal reports or may
Characteristics, as noted, be only indicator
especially in persons who present when client is
cannot communicate unable to verbalize.
verbally.
 Monitor vital signs,  Elevations in
noting increased temperature may
temperature. indicate increased

 Provide  Nonpharmacologic
nonpharmacologic pain
management.
 Identify ways to avoid or  Splinting incisions
minimize pain.
Collaborative:
 Provide for  Promotes active, rather
individualized physical
therapy or exercise
program that can be
continued by the client
after discharge.
discomfort or may
occur in response to
fever and inflammatory
process. Fever can also
increase client’s
discomfort.
methods in pain
management may
include physical,
cognitive-behavioral
strategies, and lifestyle
pain management.
Cognitive-behavioral
therapy (CBT) for pain
management. These
methods are used to
provide comfort by
altering psychological
responses to pain.
during cough, keeping
body in good alignment
and using proper body
mechanics, and resting
between activities can
occurrence of muscle
tension or spasms, or
undue stress incision.’
than passive, role and
enhances sense of
control.
 ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTIONS
Subjective: Risk for Ineffective Airway Short-term Goal: Independent: Goal Met
"I’m having a little Clearance r/t After 1 hour of nursing  Administer medications  Expectorants increase Short-term Goal:
trouble breathing but I Tracheobronchial interventions, the patient as indicated; productive cough to clear After 1 hour of nursing
guess it’s okay" as Obstruction will demonstrate expectorants the airways. They liquefy interventions, the
verbalized by the reduction of congestion lower respiratory tract patient has
patient. with breath sounding secretions by reducing its demonstrated reduction
clear, noiseless viscosity. of congestion with
respirations, and  Assist with breath sounding clear,
 Bronchoscopy is
Objective: improved oxygen bronchoscopy if noiseless respirations,
occasionally needed to
 Ineffective cough exchange. indicated. and improved oxygen
remove mucous plugs,
 dullness to exchange.
drain purulent secretions,
percussion Long-term Goal:
obtain lavage samples for
 bronchial breath After 8 hours of nursing Long-term Goal:
culture and sensitivity.
sounds intervention, Patient will After 8 hours of nursing
 BP: 100/60 mmHg maintain effective Dependent: intervention, Patient has
 RR: 31 cpm respiratory pattern with  Doing so would lower maintained effective
 Elevate head of bed, the diaphragm and
 PR: 115 bpm airway patent or change position respiratory pattern with
 Temp: 38.6 aspiration prevented. promote chest expansion, airway patent or
frequently. aeration of lung aspiration prevented.
segments, mobilization
and expectoration of
secretions.

 Teach and assist patient  Deep breathing exercises

with proper deep-
breathing exercises.
Demonstrate proper
splinting of chest and
effective coughing
while in upright
position. Encourage him
to do so often.
 Maintain adequate  Fluids, especially warm
hydration by forcing
fluids to at least 3000
mL/day unless
facilitates maximum
expansion of the lungs
and improves the
productivity of cough.
Coughing is a reflex and
it is the most helpful way
to remove most
secretions. Splinting
reduces chest discomfort
and an upright position
favors deeper and more
forceful cough effort
making it more effective.
liquids, aid in
mobilization and
expectoration of
 contraindicated. Offer secretions.
warm, rather than cold,
fluids.  Nebulizers humidify the
 Assist and monitor airway to thin secretions
effects of nebulizer and facilitates
treatment and other liquefaction and
respiratory expectoration of
physiotherapy: chest secretions, and chest
percussion percussion helps loosen
and mobilize secretions
in smaller airways that
cannot be removed by
coughing or suctioning.
 Helps mobilize
 Encourage ambulation. secretions and reduces
atelectasis.
 Increasing the humidity
 Use humidified oxygen will decrease the
or humidifier at viscosity of secretions.
bedside. Clean the humidifier
before use to avoid
bacterial growth.

Collaborative:  These measures are

 Anticipate the need for
supplemental oxygen or
intubation if patient’s
condition deteriorates.
 Monitor serial chest x-
rays, ABGs, pulse  Follows progress and
oximetry readings.
needed to correct
hypoxemia. Intubation is
needed for deep
suctioning efforts and
provide a source for
augmenting oxygenation.
effects and extent of
pneumonia. Therapeutic
regimen, and may
facilitate necessary
alterations in therapy.