ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Objective: Ineffective Short term: Independent: Short term:

BP: 130/80 breathing pattern After 30 minutes of  Suction airway as needed.  To clear secretions After 30 minutes of
T: 37.5 Celsius related to nursing nursing
PR:89 increased work of interventions the  Encourage lower or deeper  To assist the client take control interventions the
RR:30 breathing patient will respiration, use of pursed-lip of the situation patient has:
secondary airway establish a normal, technique - established a
The patient has a obstruction as effective respiratory normal,
history of manifested by pattern as  Encourage a position of comfort,  To promote ventilation to effective
smoking for 40 fatigue, evidenced by reposition the client every 2 hrs COPD patients and mobility of respiratory
yrs. breathlessness, absence of: secretions pattern as
use of accessory  Monitor pulse oximetry as evidenced by
The patient is muscles when  Respiratory indicated  To verify improveme nt of O2 absence of:
experiencing breathing, distress saturation  respiratory
tachypnea, intercostal  Tachypnea  Encourage adequate rest periods distress
respiratory retractions, and  Abnormal  to limit fatigue  tachypnea
distress, use of tachypnea  arterial  Review environmental factors  abnormal
accessory blood gas such as severe weather, arterial
muscles, and has  fatigue exposure to dust or high pollen  avoidance of triggers and blood gas
intercostal counts environment to limit impact on  fatigue
retraction. the client's breathing
Long term:  Discuss the relationship of
The patient Within 8 hrs of smoking to respiratory function, Long term:
experiences nursing emphasize the importance of Within 8 hrs of
breathlessness. Interventions the smoking cessation and a smoke nursing
patient will: free environment interventions the
The patient has patient was able to:
productive cough - Verbalize Dependent: - Verbalize
with white awareness of  Administer oxygen at the lowest awareness of
secretion. causative concentration indicated as 2- causative
factors 3LPM  for management of underlying factors
- Demonstrate pulmonary condition and - Demonstrate
appropriate  Nebulization of Salbutamol + respiratory distress appropriate
coping Ipratropium now, then every 6 coping
behaviours hours.  relaxes airway muscle making it behaviours
easier to breath
 Acetylcysteine (Fluimucil) 400mg
1 sachet dissolved 1/2 of H2O GOAL MET.
every 6 hours, can be started  mucolytic agent to promote
tomorrow morning. airway clearance

 Tazobac (Piperacillin sodium) 4.5  to treat pneumonia

g thru soluset dissolved in PNSS
90 cc x 1hr OD ANST