NURSING NURSING

ASSESSMENT INFERENCE GOAL RATIONALE EVALUATION

DIAGNOSIS INTERVENTION

Subjective:  Ineffective Irritant  After 30  Pain was  Helps to  After

a
“nahihirapan ako airway minutes of assessed, achieve 30
clearance nursing encouraged maximal minut

vi
huminga” as
verbalized by the r/t lung interventio deep lung es of
patient. impairment n, patient breathing inflation nursin

d
Inflammatory airway is and and to g

e
Objective: achieved coughing open interv

ar
- Use of and there exercises closed ention
accesso is airways . The

sh
ry improvem goal
muscles ent in the  Amount,  Changes is met
response airway viscosity, in sputum throug
during

as
inhalatio clearance color and may h the
n and odor of suggests patien

w
expiratio sputum presence t
Increase were of verbal
n

m e
production of monitored infection izing
- Chest
tube
intact co rc
secretions
Dependent
that
he is
o. ou
and  Administ  Secretion free of
draining er s must be acute
distre
er res
to dark humidific moistened
red ation and ss
Airways and thinned if and
exudate
constriction nebulize they are feels
s
se dy

r to be much
theraphy raised more
ur tu

as from the comfo

prescrib chest with rtable.
s
H
is
Th

This study source was downloaded by 100000830575513 from CourseHero.com on 11-16-2021 05:43:46 GMT -06:00
 dyspnea ed the least
amount of
effort

Independent

a
 Pain limits

vi
 Location chest
, excursion
characte and

d
r and decreases

e
severity ventilation

ar
of pain
was

sh
evaluate
d.  The

as
patient
who is in

w
semi-
 Maintain fowlers
ed care permits

m e
in residual
co rc positioni
ng the
air in the
plural
o. ou
patient. space to
Placed rise to
er res

in a upper
semil portion of
Fowler’s pleural
se dy

position space and

and be
turning removed
ur tu

or the
patient
s
H
is
Th

This study source was downloaded by 100000830575513 from CourseHero.com on 11-16-2021 05:43:46 GMT -06:00
 NURSING NURSING
GOAL
ASSESSMENT DIAGNOSIS INFERENCE INTERVENTION RATIONALE EVALUATION

a
Subjective  Acute Trauma After 30  Location,  Pain limits After 30

vi
“medyo paint r/t minutes of character, chest minutes of
drainage, nursing quality and excursion nursing
kumikirot ung
incision intervention, severity of and intervention

d
dibdib ko” as Release of pain intensity the patient will
pain was thereby

e
verbalized of the arachidonic as verbalized evaluated decreases verbalize

ar
patient. acid will be lessen ventilation signs of free
from 7/10 to  Px position in  Semi from distress

sh
Objective: 4/10 semi-fowler fowler and
helps the comfortable.
Increase patient in There is no

as
 Facial
prostaglandin expanding sign of
grimace
and less incisional

w
pain will infection.
 P/S of
7/10 be felt by

m e
pain the patient

co rc  Incision of
drainage was
 Signs of
indication
o. ou
assessed for for
redness and infection
er res

drainage  It
 Encourage for promotes
deep patient for
unlabored
se dy

breathing
exercise breathing
ur tus
H
is
Th

This study source was downloaded by 100000830575513 from CourseHero.com on 11-16-2021 05:43:46 GMT -06:00
Powered by TCPDF (www.tcpdf.org)