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  After 2 days of respiratory rate and rate and rhythm
RELATED TO
akog huminga at TRACHEO- nursing depth by listening to changes are After 2 days of
Amounts of fluid are
saka kinakapos BRONCHIAL intervention, the lung sounds. early warning nursing
drained from the
ako sa OBSTRUCTION client will be able signs of intervention, the
pleural cavity
paghinga.” SECONDARY to: impending client will be able
TO PLEURAL  respiratory to:
Establish a Note muscles
EFFUSION AS difficulties.
 fluid pressure in normal/effective used for Establish a
OBJECTIVE: EVIDENCED breathing(sterno-
the pleural cavity respiratory pattern these signify normal/effective
BY DYSPNEA 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 Atelectasis in the
nostrils normal skin color.
physical affected side of the
discomfort lung position client
SHORT TERM with proper body
use of  This is for good SHORT TERM
OUTCOME: alignment(semi-
accessory lung excursion
Impaired cardiac fowler’s position) OUTCOME
muscle noted After 4 hours of and chest
filling/inflamed ACHIEVED:
pleural membranes nursing expansion
oxygen in use
intervention, the After 4 hours of
via nasal Ensure that
(intensified on client will be able nursing
cannula, 2- oxygen delivery 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 delivered awareness of
breathing, altered
causative factors
chest excursion, demonstrate pace and
respiratory depth appropriate demonstrate
schedule activities
changes coping behaviors appropriate
providing adequate
like proper This prevents coping behaviors
rest periods
breathing and dyspnea resulting like proper
from fatigue
Reference: Medical coughing Encourage breathing and
Surgical sustained deep coughing
these promote
Nursing:Brunner 11th breaths by
deep inspiration
edition, p.652 emphasizing slow
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.