Pulmonary Embolism

Assessment Nursing Planning Implementation Rationale Evaluation

Diagnosis

Subjective Ineffective Short term: Independent: 1).Pulmonary Short-term goal

data: breathing embolism is a has met. After 8
pattern may be After 8 hrs of 1). Assess the sudden acute hrs of nursing
"Sobrang related to chest nursing client’s anxiety condition that can interventions,
sumasakit ang pain and interventions level. produce anxiety. the client
dibdib ko sa hypoxia as the client Anxiety can result manifest
bawat oras na evidenced by should in rapid, shallow effective
humihinga ako desaturation, manifest respirations and breathing and a
at madalas dyspnea, effective increase dyspnea. It decrease in
akong impaired chest breathing and can be a sign of pain scale from
nahihirapan excusrion, a decrease in decreasing 8/10 - 1/10.
huminga" as tachypnea, pain scale of hypoxemia.
verbalized by tachycardia, 8/10
the patient and
Long-term goal
restlessness.
2). Respiratory rate has met. The
Long term: and rhythm patient
Objective changes are early manifest
Data: After 24 hrs of
2). Assess the signs of impending absence of
nursing
respiratory rate, respiratory distress. dyspnea and
Pain scale: interventions
rhythm, and Tachypnea is a stable vital
8/10 the patient
depth. Assess for typical finding of signs. The
patient will
Facial grimace any increase in the pulmonary patient has
maintain
is present work of breathing: embolism (PE). The effectively
effective
shortness of rapid, shallow mantained
breathing
VS: breath, and the respirations results normal
pattern, as
use of accessory from hypoxia. The breathing
•BP - 140/100 evidenced by
muscle. development of pattern.
relaxed
•RR - 31 bpm hypoventilation
breathing at
(slowing of
normal rate
•PR - 89 bpm respiratory rate)
and depth, and
without
•O2 Sat - 79% absence of
improvement in the
dyspnea.
client’s condition
Appearance:
indicates
Cyanotic
respiratory failure.

3). Pain is usually

sharp or stabbing
 and gets worse with
deep breathing and
coughing. It can
result in shallow
respirations, further
impairing effective
gas exchange.

3). Assess the

characteristics of 4). ABGs of these
pain, especially in clients typically
association with exhibit hypoxemia
the respiratory and respiratory
cycle. alkalosis from a
blowing off of
carbon dioxide. The
development of
respiratory acidosis
in this client
indicates
4). Monitor respiratory failure,
arterial blood and immediate
gasses (ABGs). ventilator support
is indicated.

5). Pulse oximetry is

a useful tool in the
clinical setting to
detect changes in
oxygenation.
Oxygen saturation
should be at 90% or
greater on room
air.

6). The presence of

a trusted person
may be helpful
during periods of
anxiety.

5). Monitor
oxygen saturation
as indicated.
 7). If not
contraindicated, a
sitting position
allows good lung
excursion and chest
expansion.
Repositioning
facilitates
movement and the
6). Provide
drainage of
reassurance and
secretions.
allay anxiety by
staying with the 8). Coughing is the
client during acute most productive
episodes of way to remove
respiratory secretions. The
distress. client may be
unable to perform
independently.
7). Position the Suctioning is
client in a sitting indicated when
position, and clients are unable
change the to remove
position every 2 secretions from the
hours. airways by
coughing. These
maneuvers help
keep airways open
by clearing
secretions.

9). Common tests

8). Encourage
such as a chest x-
deep breathing
ray examination
and coughing
and D-dimer assay (
exercise. Suction
a marker for clot
as indicated.
lysis) are readily
available in acute
care settings,
especially to rule
out PE. If there is a
high suspicion for
PE, then a CT scan
 and other scans are
added to make a
diagnosis. A
pulmonary
arteriogram is a
definitive test.

10). Supplemental
oxygen maintains
adequate
oxygenation,
Collaborative::
decreases the work
9). Prepare the of breathing,
client for relieves dyspnea,
diagnostic studies: and promotes
comfort. The
Chest X-ray appropriate
amount of oxygen
Computed needs to be
tomography (CT) continuously
scan delivered so the
client does not
Ventilation-
become
perfusion scan
desaturated.
Pulmonary
arteriogram
11). Intubation and
D-dimer assay
positive-pressure
ventilation are a
means to stabilize
breathing and
ventilation and
prevent
decompensation of
the client.
10). Administer
oxygen as
indicated.
 11). Anticipate the
need for
intubation and
mechanical
ventilation.

Sarcoidosis

Assessment Nursing Planning Interventions Rationale Evaluation

Diagnosis

Subjective data: Imtense pain Short term goal: Independent: Short-term go

related to has met. After 8
"Palagi nalang granulomas in • after 8 hrs of 1). Administer 1). To provide hrs of nursing
akong the lower legs nursing prescribed pain relief to the interventions
nanghihina at and joints interventions medications that patient. the patient
madalas secondary to the patient will alleviate the vetbalized "no
mawalan ng sarcoidosis, as demonstrate symptoms of pain" at all.
gana sa mga evidenced by relief of pain as pain.
gawain.. pain scale of 9 evidenced by a • normal vital
Kasabay pa nun, pain score of 0 2). Assess the signs has
out of 10, 2). To monitor
nahihirapan out of 10, stable patient’s vital manifested
verbalization of effectiveness of
akong huminga vital signs, and signs and
strain-like chest medical
at sobrang absence of characteristics of
pain, fretfulness, treatment for
sumasakit ang restlessness. pain at least 30
respiratory rate the relief of Long-term goals
aking dibdib sa minutes after
of 29 bpm, heart pain. The time have met. The
bawat paghinga administration of
rate of 120 bpm of monitoring of patient
ko" as medication.
vital signs may
verbalized by Long-term goal: depend on the manifested
the patient. peak time of the effective
• Activity • after 24 hrs of drug breathing,
• Factory intolerance nursing administered. active
worker related to interventions participation in
persistent the patient will 3). To create a desired
• (+) hx of fatigue as demonstrate baseline of activities,
sarcoidosis evidenced by active activity levels
3). Assess the maintained
verbalization of participation in patient’s and mental stabilized ormal
unrelieved necessary and activities of daily status related to vs and verbalied
Objective data: fatigue, desired activities living, as well as fatigue and absence of pain.
overwhelming and actual and activity
• Pain scale: lack of energy, demonstrate perceived intolerance.
9/10 generalized increase in limitations to
weakness, and activity levels. physical activity.
• (+) facial
shortness of Ask for any form
grimace • after 1 week
breath upon of exercise that
exertion of nursing
• (+) he/she used to
interventions
restlessness do or wants to
the patient will
try.
maintain active
participation in 4). Encourage 4). To gradually
VS: necessary and progressive increase the
desired activity through patient’s
• PR - 120 bpm activities, tolerance to
self-care and
maintain exercise as physical activity.
• RR - 29 bpm
effective tolerated. Explain To allow the
breathing the need to patient to pace
pattern, and reduce sedentary activity versus
stabilized activities such as rest.
normal vital watching
signs. television and
using social
media in long
periods.
Alternate periods
of physical
activity with 60-
90 minutes of
undisturbed rest.

5). Elevate the

head of the bed if
the patient is
short of breath.
5). To increase
Administer
the oxygen level
supplemental
oxygen, as and achieve an
prescribed. SpO2 value
Discontinue if within the target
SpO2 level is range.
within the target
range, or as
ordered by the
physician.

6). Teach deep

breathing
exercises and
relaxation
techniques.
Provide adequate
ventilation in the 6). To allow the
room. patient to relax
while at rest and
to facilitate
7). Place the effective stress
patient in management.
complete bed To allow enough
rest when in oxygenation in
severe pain. the room.
Educate patient
7). Stress may
on stress
further increase
management,
pain levels.
deep breathing
exercises, and
relaxation
techniques.

Collaborative:

8). Refer the

patient to
physiotherapy /
occupational
therapy team as
required.

8). To provide a
more specialized
care for the
patient in terms
 of helping
him/her build
confidence in
increasing daily
physical activity.

Pneumonia

Assessment Nursing Planning Intervention Rationale Evaluation

Diagnosis

Subjective data: Ineffective Short-term goal: Dependent, After 30 mins

breathing of nursing
• Chills pattern • after 30 1). Obtain 1). Gives us a interventions
related to minutes of appropriate labs baseline; the patient has
• Dyspnea nursing (antibiotic troughs, identifies
decreased verbalized less
lung intervention the sputum cultures, pathogens, and pain
• Pain
expansion patient will able ABGs, etc.) enables us to
• Altered Mental and pain as to manifest evaluate if
State (AMS) evidenced by relieve of pain interventions
are effective • after 8 hrs of
changes in Independent:
• after 8 hrs of nursing
rate, depth of
nursing 2). Enables interventions
respirations 2). Complete a full
Objective data: intervention the quicker the patient
and reduced respiratory
patient should interventions manifested
• Cough vital capacity assessment to
verbalize total and may change effevtive
detect changes or
• phlegm improvement in them (for breathing
further
breathing example, pattern and
decompensation as
• Ronchi/wheezes pattern and wheezing noted vital signs
early as possible,
display on auscultation effectively
VS: and notify MD as
increased vital would recovered
indicated
capacity. potentially
• 29 bpm
indicate steroids
• T - 38.9 and a breathing
• within week
treatment, while
Long-term goal: of nursing
• O2 Sat - 78% crackles could
interventions
• within 1 week require
normal
of nursing suctioning,
breathing
interventions repositioning,
already
the patient will and potential
maintained
fully recover fluid restriction)
and patient
from pain, reported
dyspnea, chills absence of
secondary to 3). labored
oneumonia, Normothermia breathing,
and manifest optimizes pain and chills.
stabilized oxygen
normal vital consumption
signs. 3). Promote
normothermia
• the patient
(warm patient if
should achieve
the hypothermic,
and maintain
cool patient and
effective
administer
breathing 4). Activity
antipyretics if
pattern intolerance is
hyperthermic)
common
• the patient
because of
should gain
decreased gas
enough 4). Cluster care exchange;
understanding
cluster your care
about the
to conserve your
present
patient’s energy
condition
for essential
tasks like
ambulation,
coughing, and
deep breathing,
and eating

5). We want to
encourage
coughing to
remove phlegm;
do not suppress
cough unless
clinically
indicated. If the
patient is able to
clear their own
5). Promote airway
airway, continue
clearance
to encourage
this. If not,
suction
frequently and
consider an
advanced airway
to ensure a
patent airway,
 which ultimately
maximizes gas
exchange.
Getting phlegm
out is important.

6). Patients with

pneumonia may
not be
consuming
adequate oral
intake due to
fatigue or not
feeling well, but
hydration is
essential to
healing. Patients
may need IV
fluids if PO
intake is
inadequate.

7). If patients
are not coughing
because of pain,
6). Optimize fluid
it will only allow
balance
fluid to continue
to build. Treat
pain
appropriately
and encourage
them to cough
to clear phlegm.

8). Coughing and

deep breathing
encourages
expectoration,
which enables
better gas
exchange

9). Patients with

7). Assess and treat pneumonia
pain typically tire
easily and have
poor appetites,
 but need
appropriate
nutrition and
hydration to
heal

10). Due to the

impaired gas
exchange,
oxygen doesn’t
make it into
circulation as
easily. Providing
additional
oxygen supports
this as much as
8). Encouraging possible. Use
coughing and deep caution in
breathing patients with
underlying lung
conditions.

11). Patients
Collaborative: may be on
antibiotics,
9). Promote therefore it’s
nutrition essential to
ensure they are
administered at
the appropriate
time and not
delayed, as this
will impair their
efficacy.

12). Patients
must be aware
of how these
aspects of
recovery are
10). Administer pertinent so
supplemental they will be
oxygen as more likely to
appropriate participate and
remain
compliant.
 11). Administer
antibiotics in a
timely fashion,
draw troughs
appropriately

12). Educate
patient and loved
ones on the
importance of
energy
conservation,
effective airway
clearance,
nutrition, as well as
coughing and deep
breathing

Pulmonary Tubercolosis

Assessment Nursing Planning Intervention Rationale Evaluation

 Diagnosis

Subjective Ineffective Short-term Independent: At the end of

Data: airway goals: the shift, the
clearance 1). Assess 1). Provides a client was able
"Sobrang • Within 6 hrs respiratory basis for
related to to display
nahihirapan na poor cough of nusring rate evaluating patency of
akong interventions, adequacy of
effort as airways
huminga at eveidence by the patient will ventilation manifested by:
madalas ang be able to: 2). Noted chest
abnormal 2). Use of
aking breath sounds movement; • secretions
panghihina" *display accessory decreased
and difficulty decreasing use of muscle of
of breathing accessory
amount of respiration may • Client's
secretions muscle during occur in respiratory
Objective respiration response to rate is within
Data: *achieve ineffective normal range;
normal range 3). Auscultated
• Dyspnea breath sounds; ventilation RR - 19bpm
of respiration
oted areas 3). Crackles • Client's
• Use of *manifest with presence
accessory indcates remaines calm
absence of of adventitous accumulation of and
muscle for restlessness sounds
respiration secretions and manifested
(crackles) inability to clear absence of
• Elevates 4). Document airways restlessness.
shoulders Long-term respiratory
goals: secretions;
• Abnormal
breath sounds • During the charcater and 4).
associated client's stay at amount of Expectorations
with wet the hospital, sputum may be
crackles. he will be able different when
5). Maintained
to keep patent secretions are
• Restless patient on very thick
airway as moderate high
evidence by: back rest

VS: *normal 6). Check for 5). Positioning

respiration as obstructions; helps maximize
• BP - 82/60 evidence by accumulation lung expansion
hhmg absence of of secretions
dyspnea and
• T - 36.5
wet crackles
6). To maintain
• RR- 26 cpm
*normal adequate
• PR - 75 bpm breathing Dependent: airway patency
pattern; RR =
12-20 cpm 7). Take
medication as
*absence of ordered by the
bronchial physician
secretions

*mitgate
restlessness

Pleural Effusion

Assessment Nursing Planning Intervention Rationale Evaluation

Diagnosis

Subjective Impaired Gas The patient Independent: After the

Data: Exchange will achieve nursing shift,
related to the effective 1). Check the 1). To establish a the client was
• Patient patient’s baseline. Gas
altered supply breathing able to
verbalized of oxygen pattern and breathing rate, exchange is breathe easily
difficulty of characteristics, affected by rapid
secondary to oxygen and
breathing Pleural saturation of including the and shallow manifested
involvement of breathing
• "Sobra Effusion as above 96% normal vital
evidenced by accessory patterns, as well signs as
akong muscles when as
nanghihina, frequent evidenced by
coughing, breathing, and hypoventilation. optimal gas
sumasakit ang • The patient any other Hypoxia, on the
aking dibdib difficulty of will be able to exchange,
breathing, irregular other hand, is normal
sa bawat maintain breathing characterized by
paghinga at nasal flaring, optimal gas breathing
restlessness, patterns. an increased pattern, and
madalas ang exchange and Auscultate the respiratory rate,
aking pag- use of finally stabilized vital
accessory lungs and the employment signs.
ubo" achieve ease monitor for of accessory
muscles when of breathing
breathing, and adventitious muscles, nasal
as evidence breath sounds. flaring,
increased by absence of
Objectice diaphragm
cardiac rate. cough and
Data: breathing, and a
dyspnea. panicky
• frequent
appearance in
coughing
the patient’s
• dyspnea eyes.

• use of 2). Central

accessory cyanosis of the
2). Watch out
muscle during tongue and oral
respiration for nail beds and mucosa signals
skin cyanosis, as severe hypoxia
well as the color and requires
of the tongue
VS: immediate
and oral mucous medical
• RR - 29 bpm membranes. attention,
whereas
• PR - 120
peripheral
bpm
cyanosis of the
• Oxygen Sat.- extremities may
89% or may not be
significant.

3). Constantly 3). Pulse

monitor the oximetry is an
patient’s oxygen effective method
saturation for detecting
through a pulse oxygenation
oximeter. abnormalities.
Significant
oxygenation
concerns are
indicated by an
oxygen
saturation of less
than 90% or a
partial pressure
of oxygen of less
than 80.

4). Constantly 4). Elevated

check the Carbon dioxide
results of blood levels and
chemistry and diminishing
arterial blood levels of oxygen
gases (ABG). may indicate
respiratory
acidosis and
 hypoxemia (low
level of blood
oxygen,
particularly in
the arteries).

5). Improved
thoracic
capacity,
5). Place the
complete
patient in a high
diaphragm fall,
or semi-Fowler’s
and increased
position with
lung expansion
the head of the
prevent
bed elevated.
abdominal
Also, encourage
contents from
the patient to sit
crowding when
in an upright
placing the
position if
patient in the
tolerated.
upright or semi-
Fowler’s
position.

6). Ventilation
6). Analyze the and perfusion
influence of imbalances are
shifting aggravated by
positions on positioning the
ABGs and pulse patient’s most
oximetry impaired lung
readings. regions in the
dependent
position, where
perfusion is
greatest.

7). The patient’s

7). Monitor the abdomen
patient’s compresses the
position at a diaphragm and
regular interval inhibits
to ensure that adequate lung
they do not expansion while
slump in bed. he or she is in
slumped or
slouched
position.

8). Gas exchange

is hindered by
8). Encourage excessive
the patient to secretions that
cough and have
practice deep accumulated in
breathing the lungs.
techniques. Coughing and
deep breathing
exercises will
help the patient
evacuate
secretions from
his or her lungs.

9). Oxygen
therapy may be
necessary to
maintain the
Dependent: adequate oxygen
level of the
9). Administer
patient.
supplemental
oxygen as
directed by the
attending
physician,
aiming for an
oxygen 10). Humidified
saturation level oxygen
of 90% or above. minimizes the
risk of drying out
10). Deliver
the lungs of the
humidified
patient.
oxygen as
ordered by the 11). Anxiety
physician. makes signs and
symptoms
including
11). Assist the shortness of
patient in breath,
alleviating their respiratory rate,
anxiety level by and effort in
providing breathing worse.
reassurance. 12). Chest
expansion,
secretion
evacuation, and
deep breathing
12). Promote or
are all improved
assist
by ambulation.
ambulation in
patients who
are ambulatory,
as 13).
recommended Thoracentesis is
by the attending a slightly
physician. invasive medical
management in
13). Prepare the which a needle is
patient for the inserted through
procedure of the chest wall
thoracentesis. into the pleural
space to extract
fluid or air from
around the lungs
in order to
diagnose and
treat pleural
effusions.

14).
Pleurectomy,
which involves
surgically
separating the
parietal and
visceral layers of
 the lungs,
induces an
14). Start inflammatory
preparing the response that
patient for leads to
pleurectomy or adhesion
pleurodesis formation
procedure as between the two
indicated by the layers as they
attending regenerate.
physician if Pleurodesis, on
pleural effusion the other hand,
occurs is a procedure
repeatedly. that includes
infusing a
sclerosing
substance into
the area
between the
lung and the
chest wall to
prevent fluid or
air from
accumulating
between the
layers.

15). To provide
further
knowledge and
personalized
treatment to the
patient, resulting
in enhanced gas
exchange

Collaborative:

15). Refer the

patient to a
chest
 physiotherapist
as necessary.

Pneumothorax

Assessment Nursing Planning Intervention Rationale Evaluation

Diagnosis

Subjectuve Ineffective • Establish a 1). Determine 1). After the

Data: breathing normal/effectiv etiology and Understanding nursing shift, tje
pattern may e respiratory precipitating the cause of patient
• Patient be related to pattern with factors lung collapse is demonstrated
verbalized decreased ABGs within (spontaneous necessary for the following:
pain with a lung patient’s normal collapse, proper chest
score of 10 • Pain is
expansion range. trauma, tube
out of 10 in (air/fluid malignancy, placement and relieved
pain scale • Report
accumulation) infection, a choice of other • Established a
, pain, and absence of pain complication therapeutic
• (+) hx of normal,
pneumothora anxiety • Increase of mechanical measures. effective
x possibly perfusion ventilation). respiratory
evidence by pattern as
difficulty of • Be free of 2). Check out
respiratory 2). Respiratory evidenced by
breathing, cyanosis and distress and absence of
Objective other function,
cyanosis, changes in vital cyanosis.
Data: noting rapid or
abnormal signs/symptoms signs may
ABGs and of hypoxia. shallow • Demonstrated
• Cyanotic occur as a
respirations, increase in
altered chest result of
• Tachyonea excursion dyspnea, perfusion.
reports of “air physiological
• Dyspnea stress and pain • Patient is
hunger,”
development or may indicate relaxed and
• Facial the
of cyanosis, reported
grimace development
changes in anxiety is
of shock due to reduced to a
• abnormal vital signs.
hypoxia or manageable
ABGs
hemorrhage. level.
(respiratory
alkalosis) 3). Observe for 3). Difficulty • Adhered to
synchronous breathing prescribed
• Irregular
respiratory “with” pharmacologica
breathing
pattern when ventilator and l regimen.
using a increasing
mechanical airway
ventilator. pressures
Note changes suggests
in airway worsening of
pressures. condition or
development
of
complications
(spontaneous
rupture of a
bleb creating a
new
pneumothorax
).
4). Auscultate
breath sounds. 4). Breath
sounds may be
diminished or
absent in a
lobe, lung
segment, or
entire lung
field
(unilateral).
Atelectatic
area will have
no breath
sounds, and
partially
collapsed areas
have
decreased
sounds.
Regularly
scheduled
evaluation also
helps
determine
areas of good
air exchange
 and provides a
baseline to
evaluate the
resolution of
pneumothorax

5). Chest
excursion is
unequal until
5). Note chest
lung re-
excursion and
expands.
position of the
Trachea
trachea.
deviates away
from the
affected side
with tension
pneumothorax

6). Voice and

tactile fremitus
6). Assess for (vibration) are
fremitus. reduced in
fluid-filled or
consolidated
tissue.

7). Supporting
chest and
abdominal
muscles make
7). Assist coughing more
patient with effective and
splinting less traumatic.
painful area
when 8). Promotes
coughing, deep maximal
breathing. inspiration;
enhances lung
expansion and
ventilation in
8). Maintain a
unaffected
position of
side.
comfort,
usually with
the head of
bed elevated.
Turn to the 9). Assists
patient to deal
affected side.
Encourage with the
physiological
patient to sit
up as much as effects of
hypoxia, which
possible.
may be
9). Maintain a manifested as
calm attitude, anxiety or fear.
assisting the
10). Maintains
patient to
“take control” prescribed
intrapleural
by using
slower and negativity,
which
deeper
respirations. promotes
optimum lung
expansion and
fluid drainage.
10). Once the Note: Dry- seal
chest tube is setups are also
inserted: used with an
automatic
control valve
(AVC), which
provides a one-
way valve seal
similar to that
achieved with
the water-seal
system.

11). Water in a
sealed
chamber
serves as a
barrier that
prevents
atmospheric
air from
entering the
 pleural space
should the
suction source
11). Check be
suction control disconnected
chamber for a and aids in
correct evaluating
amount of whether the
suction chest drainage
(determined system is
by water level, functioning
wall or table appropriately.
regulator at 12). Bubbling
correct setting; during
expiration
reflects venting
of
pneumothorax
(desired
action).
Bubbling
usually
decreases as
12). Observe
the lung
water-seal
expands or
chamber
may occur only
bubbling
during
expiration or
coughing as
the pleural
space
diminishes.
Absence of
bubbling may
indicate
complete lung
re-expansion
(normal) or
represent
complications
such as
 obstruction in
the tube.

13). With
suction
applied, this
indicates a
persistent air
leak that may
be from a large
pneumothorax
at the chest
insertion site
(patient-
centered) or
chest drainage
unit (system-
13). Observe centered).
for abnormal
and 14). If bubbling
continuous stops when the
water-seal catheter is
chamber clamped at the
bubbling insertion site,
leak is patient-
centered (at
insertion site
or within the
patient).

15). Usually
corrects
insertion site
air leak.

14). Know the

location of air
leak (patient-
or system-
centered) by
16). Isolates
clamping
thoracic location of a
catheter just system-
distal to exit centered air
from the chest. leak.Note:
Information
indicates that
15). Place clamping for a
petrolatum suspected leak
gauze and may be the
other only time that
appropriate the chest tube
material should be
around the clamped.
insertion as 17). Prevents
indicated. and corrects air
16). Clamp leaks at
tubing in connector
stepwise sites.
fashion
downward
toward the
drainage unit if
air leak
continues

18). The water-

seal chamber
serves as an
intrapleural
manometer
17). Seal (gauges
drainage intrapleural
tubing pressure);
connection therefore,
sites securely fluctuation
with (tidaling)
lengthwise reflects
tape or bands pressure
according to differences
established between
policy inspiration and
18). Monitor expiration.
water-seal Tidaling of 2–6
chamber cm during
“tidaling.” inspiration is
Note whether normal and
the change is may increase
transient or briefly during
permanent coughing
episodes.
Continuation
of excessive
tidal
fluctuations
may indicate
the existence
of airway
obstruction or
the presence
of a large
pneumothorax

19). .Improper
position,
kinking, or
accumulation
of clots or fluid
in the tubing
changes the
desired
negative
pressure and
impedes air or
fluid
evacuation.
Note: If a
dependent
loop in the
drainage tube
cannot be
avoided, lifting
and draining it
every 15 min
19). Position will maintain
drainage adequate
system tubing drainage in the
for an optimal presence of a
function like hemothorax.
shorten tubing
or coil extra 20). Useful in
evaluating
tubing on the
bed, making resolution of
pneumothorax
sure tubing is
not kinked or and
development
hanging below
the entrance of hemorrhage
requiring
to drainage
container. prompt
intervention.
Drain
accumulated Note: Some
drainage
fluid as
necessary systems are
equipped with
an
autotransfusio
n device, which
allows for
salvage of shed
blood.

21). Although
routine
20). Assess the
stripping is not
amount of
recommended,
chest tube
it may be
drainage,
necessary
noting
occasionally to
whether the
maintain
tube is warm
drainage in the
and full of
presence of
blood and
fresh bleeding,
bloody fluid
large blood
level in the
clots or
water-seal
purulent
bottle is rising
exudate
 (empyema).

22). Stripping is
usually
uncomfortable
for the patient
because of the
21). Evaluate change in
the need for intrathoracic
tube stripping pressure,
(“milking”) which may
induce
coughing or
chest
discomfort.
Vigorous
stripping can
create very
high
intrathoracic
suction
pressure,
which can be
injurious
(invagination
of tissue into
catheter
22). Strip tubes
eyelets,
carefully per
collapse of
protocol, in a
tissues around
manner that
the catheter,
minimizes
and bleeding
excess
from rupture
negative
of small blood
pressure
vessels).
 •Pneumothora
x may recur,
requiring
prompt
intervention to
prevent fatal
pulmonary and
circulatory
impairment.

23). If the
thoracic
catheter is
disconnected
or dislodged:

• Observe for
signs of
respiratory • Early
distress. If detection of a
possible, developing
reconnect complication is
thoracic essential
catheter to (recurrence of
tubing or pneumothorax,
suction, using presence of
clean infection).
technique. If
the catheter is
dislodged from
the chest,
cover insertion
site
immediately
with
petrolatum
dressing and
apply firm
pressure.
Notify
physician at
• Monitors
once.
progress of
24). After the resolving
thoracic hemothorax or
catheter is pneumothorax
removed: and re-
expansion of
• Cover the lung. Can
insertion site identify
with a sterile malposition of
occlusive the
dressing. endotracheal
Observe for tube (ET)
signs and affecting lung
symptoms that re-expansion.
may indicate
recurrence of • Assesses
pneumothorax status of gas
(shortness of exchange and
breath, reports ventilation,
of pain. need for
Inspect continuation or
insertion site, alterations in
note character therapy.
of drainage).

• Review serial
• Aids in
chest x-rays.
reducing work
of breathing;
promotes relief
 of respiratory
distress and
cyanosis
associated with
hypoxemia.

• Monitor and
graph serial
ABGs and
pulse
oximetry.
Review vital
capacity and
tidal volume
measurements
.

• Administer
supplemental
oxygen via
cannula, mask,
or mechanical
ventilation as
indicated.

Asthma
Assessment Nursing Planning Intervention Rationale Evaluation
Diagnosis

Subjective Data: Activity Child will engage 1). Assess the 1). Provides After the nursing
intolerance in normal presence of information shift, the patient
• A 10 year old related to activities with weakness and about energy has no longer
patient has fatigue and absence of fatigue caused reserves as struggling from
reported airway problem fatigue and by airway dyspnea and a constant
constant fatigue as evidence by airway problem problem. work of fatigue and was
and difficulty of tired breathing over a able to perform
breathing appearance, period of time activities free
lethargy, wears out these from irritating
• "Nahihirapan 2). Encourage
prolonged reserves. cough
pong huminga activities such as
dyspnea due to
ang anak ko at quiet play, 2). Avoids
an asthma
madali syang reading, change in
attack, and
mapagod kahit watching respiratory
inability to
sa mga simpleng movies, games status and
speak, eat, play
paglalaro lang. during rest. energy depletion
due to excessive
• (+) hx of
asthma activity.

3). Conserves
3). Disturb only
energy and limits
Objective Data: when necessary,
interruption in
perform all care
• Abnornal rest.
at one time
wheezing breath instead of
sound spreading over a
long period of
• Dyspnea
time, avoid
• restlessness doing any care
or procedures
• constant during an attack.
coughi
4). Schedule and
• presence of provide rest
sticky mucus periods in a calm
peaceful 4). Promotes
environment. adequate rest
and decreases
VS taken as
5). Explain the stimuli.
follows:
reason for the
T - 37. 4 need to
conserve energy
5). Promotes
P - 115 bpm and avoid
understanding of
fatigue to
the effect of
R - 33 bpm parents and activity on
child. breathing and
BP - 110/80 the need for rest
mmhg 6). Assist in to prevent
planning a fatigue.
schedule for
bathing, feeding, 6). Provides care
rest that will while promoting
save energy and activities of daily
prevent an care.
attack or
promote
resolution of an
attack.

7). Reinforce
activity or
exercise
limitations

if these trigger 7). Provides

attack; advise preventive
physician measures to
approved offset possible
activities attack.
(aerobics,
walking,
swimming).

Chronic Obstructive Pulmonary Disease

Assessme Nursing Planning Intervention Rationale Evaluation

nt Diagnosis

Subjective Ineffective Short-term 1). Establish Rapport 1). To gain Short-term

airway goal: patient’s trust. goal:
"Hirap ako clearance (achieved)
sa pag- related to After 5-8 hours 2). This
ubo at of nursing 2). Assess level of information is After 8 hours
bronchospas consciousness/cogni
nahihirap m, increased interventions essential for of nursing
an akong the client will tion and ability to identifying intervention
production protect own airway.
huminga" of tenacious be able to: potential for s the client
as airway problems, was able to:
secretions as • Maintain
verbalized evidenced by providing
by the airway patency, baseline level of • Maintain
patient presence of clear breath care needed, and airway
wheezes sounds upon influencing patency and
Objective auscultation choice of manifest
• interventions. clear
•Expectorate/ breathe
Tachypne clear secretions 3). Indicative of
a • sounds
readily respiratory
Nasal distress and/or • Exectorate
flaring • accumulation of secretions
Pale lips secretions. readily
and oral Long-term
goals: 3). Monitor
mucous 4) To determine
respirations and
membran After 2-3 weeks ability to protect
breath sounds, Long-term
e of nursing own airway
noting rate and goals:
• Use of interventions sounds (e.g., 5). To clear (achieved))
the client will tachypnea, stridor,
accessory airway when
muscle be able to: crackles, or wheezes) excessive or • After 2
indicative of weeks of
when • Manifest viscous
breathing respiratory distress secretions are nursing
stable vital intervention
signs and/or accumulation blocking airway
• Cyanosis of secretions. or client is unable s the client
• Get rid of was now
• With to swallow or
tenacious 4). Evaluate client’s able to:
productiv cough effectively.
cough/gag reflex,
e cough of secretions • Maintain
amount and type of 6). To take
thick, • Verbalize secretions, and advantage of stable vital
gelatinous understanding swallowing ability signs as
gravity
sputum of cause(s) and decreasing evidence by
5). Suction nose, absence of
• Stocky therapeutic pressure on the
management mouth, and trachea abnormal
build • diaphragm and
PRN RR, PR, T, BP
Wheezes regimen enhancing
drainage rate.
upon • Demonstrate
auscultati of/ventilation to • Manifest
absence/reduc
on on different lung the full
tion of
both lungs segments. absence of
congestion with
during breath 7). Pursed-lip tenacious
inspiration sounding clear secretions
breathing is used
and improved for dyspneic
• Capillary •
refill < 3 oxygen episodes to Demonstrat
exchange encourage the
seconds e reduction
(absence of patient to breath of
6). Elevate head of
cyanosis bed, encourage early out longer that congestoons
ambulation, or will increase the as evidenced
change client’s patient’s oxygen by clear
position every 2 hr. levels. breath
Diaphragmatic sound upon
breathing uses auscultation
abdominal and has an
muscles rather improved
than accessory ocygen
muscles which exchanged
helps to as evidenced
strengthen the by absence
diaphragm, slows of cyanotic
down the appearance.
breathing rate.
7). Teach about
pursed-lip breathing 8. Induced
and diaphragmatic coughing and
breathing deep breathing
helps improve
8). Encourage deep-
clearing
breathing and
secretions and
coughing exercises.
increases
oxygenation.

9). To relax
smooth
respiratory
musculature,
9). Administer
reduce airway
medications (e.g.,
edema, and
expectorants, anti-
mobilize
inflammatory
secretions.
agents,
bronchodilators, and 10). Hydration
mucolytic agents), can help prevent
as indicated the accumulation
of viscous
10). Increase fluid
secretions and
intake to at least
improve
2,000 mL/day within
secretion
cardiac tolerance
clearance.
(may require IV in
Monitor for
 acutely ill, signs/symptoms
hospitalized client). of congestive
heart failure
(crackles, edema,
or weight gain)
when the client is
at risk.

11). Various
therapies/modali
ties may be
required to
acquire and
maintain
adequate airways
11). Perform or assist
and improve
the client in learning
respiratory
airway clearance
function and gas
techniques, such as
exchange
postural drainage
and percussion 12). Information
(chest physical about the
therapy [CPT] disease and its
possible
outcomes might
12). Educate about improve
the disease process compliance with
and lifestyle the treatment
modifications plan
regarding COPD.
Support
reduction/cessation
of smoking.

Bronchitis

Assessment Nursing Planning Intervention Rationale Evaluation

Diagnosis
Subjective Ineffective Short-term Independent: Short-term:
airway goals:
"I'm having clearance 1). Assess 1). Useful in After 8 hours
trouble in After 8 hours respiratory evaluating the of nursing
related to
breathing and excessive, of nursing rate, depth. degree or interventions,
struggling with interventions Note useof respiratory the client was
thickened
constant mucous the patient accessory distress and able to:
irritating will: muscles, chronicity of
secretions • Demonstrate
cough" as pursed lip the disease
verbalized by •Demonstrate breathing, process. improve
improved ventilation and
rhe client inability to
ventilation and speak. enough oxygen
adequate as evidenced
2). Oxygen
oxygen. 2). Elevate by a normal
Objective head of the delivery may breathe sound
• Arterial be improved
• Presence of bed, assist and normal
blood gases patient assume by upright rate of O2 sat.
ronchi (ABGs)within position and
position toease
• Ineffective normal range. work of breathing • Maintain
coughing exercises to normal range
• No signs of breathing.
Encourage decrease of ABG
V/S taken as respiratory airway
distress. deep slow or • Manifest no
follows: collapse,
pursed lip sign of
dyspnea and
T - 36.9 breathing as respiratory
individually work of
Long term: breathing. distress
P - 85 tolerated or
After 4-5 indicated
R - 26
weeks of
3. Routinely 3). Cyanosis Long-term
BP - 110/80 nursing
monitor skin may be
interventions, After 4 weeks
and mucous peripheral in
the patient: of nursing
membrane nail beds or interventions
• Ventilation color. central in lips the patient
or oxygenation or ear lobes. was now able
is enough to Duskiness to:
meet self-care andcentral
needs cyanosis • Maintain
indicate effective
advanced ventilation and
hypoxemia oxygenation in
4). Encourage meeting self-
expectoration 4). Thick, care needs.
tenacious,
of sputum; copious
suction when secretions are
indicated major source if
ineffective
airways. Deep
suctioning may
be required
when cough
isineffective
for
expectoration
of secretions

5). During
severe or
acute
5). Evaluate
respiratory
level of activity
distress,
tolerance.
patient may be
Provide calm
totally unable
and quiet
to perform
environment
basic self-care
activities
because of
hypoxemia and
dyspnea

6). Multiple
external
stimuli and
presence of
6). Evaluate dyspnea may
sleep patterns, prevent
note report of relaxation and
difficulties and inhibit sleep.
whether
patient feels 7) Tachycardia,
well rested. dysrhythmias,
and changes in
7). Monitor blood pressure
vital signs can reflect
andcardiac effect of
rhythm systemic
 hypoxemia on
cardiac
function

8). May correct

or prevent
worsening of
Collaborative hypoxia

8).Administer
supplemental
oxygen as
indicated by
ABG results
and patients
tolerance

Acute Respiratory Distress Syndrome (ARDS)

Assessment Nursing Planning Intervention Rationale Evaluation

Diagnosis

Subjective Ineffective After 8 - 24 1). Assess the 1). Change in rate After the
breathing hours of rate, rhythm, and and depth of several
"Hirap ako sa pattern nursjng shift, depth of respiration is the hours of
paghinga, related to the client will respiration. early sign of nursing shift;
inuubo, at decreased able to: respiratory
nanghihina" • the
lung difficulty. In the
as stated by compliance • case of pulmonary patient takes
the patient demonstrate relaxed
and increased oedema and
breathing rate normal other pulmonary breathing at
breathing a normal
possibly conditions, gas
Objective evidence by pattern; rate exchange in the rate and
and depth depth. There
shortness of lungs is impaired,
• Shortness of is the
breath, • display which leads to
breath absence of
excessive absence of hypoxemia as a
cough, result rate and dyspnea and
• Restlessness dyspnea and blood gas
tachypnea, excessive depth of
analysis
• Constant dyspnea, coughing respiration shows
coughing restlessness, increase. normal
and changes • manifest parameters.
• Nail normal rate 2). When lung
in depth of
clubbing respiration in bood gas compliance • The
analysis 2). Check for the decreases, it patient
Bilateral
use of accessory impacts the work verbalizes
opacity in of breathing and his/her
chest x-ray muscles.
it increases comfort
V/S taken as significantly. In without any
foolow, this case, the air sign of
in and out in the dyspnea.
• PR - 110 lungs become
bpm more difficult. • Display a
decreased in
Lungs could not
• RR - 26 bpm level of
meet the oxygen
excessive
• BP - 130/90 demand of the
body. Breathing coughing
patterns alter in • The patient
this stage to maintains
provide adequate adequate
oxygen to the gas
body. exchange as
3). An increase in evidenced by
normal ABG
pulmonary
oedema cause findings
fluid to move into
alveoli, as a result,
3). Assess the a crackles sound is
breath sound of heard.
the lungs.
4). Dyspnea
causes an
increase in
anxiety in the
patient. Anxiety
4). Check for any
leads to increase
sign of dyspnea.
oxygen demand
of the body and
breathing pattern
is altered.
 5). Bluish
discolourisation of
the tongue,
mucus membrane
and skin indicates
a decrease in
oxygen
5). Assess for any
concentration in
sign of cyanosis.
the blood. It also
indicates that the
current breathing
pattern is not
effective to meet
the oxygen
demand.

6). Pulse oxymetry

and ABG analysis
help to interpret
the current
oxygen status in
the blood. In
ARDS, oxygen
saturation
decreases.
6). Check oxygen
Oxygen saturation
concentration in
of the body
pulse oximeter
should be kept at
and do an
90% or higher.
arterial blood gas
ABG also indicates
analysis.
respiratory
acidosis or
alkalosis or
hypoxemia.

7). An increase in
pulmonary
oedema and fibrin
build up stimulate
cough reflex and
it leads to an
 increase in cough.

8). As the rate and

depth of
breathing
7). Assess for any increases, it
cough. involves accessory
muscles and the
work of breathing
increases.
Increased work of
lungs increases
energy
expenditure and
also increase
8). Check for the
oxygen demand.
energy level of
the patient. 9). A decrease in
oxygen
concentration in
the blood leads to
alteration in brain
function. There
may be an
increase in
restlessness,
confusion and
irritability.

10). The presence

of relatives or any
trusted person
9). Assess the may help the
patient's level of patient feel less
consciousness fear and can
reduce anxiety as
well as reduce
oxygen demand.

11). Check oxygen

saturation
through pulse
oxymetry after a
 change in
position. If
10). Reassure the saturation drops
patient and down reposition
reduce the the patient as
anxiety during previous. Prone
acute episodes of position improves
respiratory oxygen saturation
distress. in ARDS patients
who are receiving
mechanical
ventilation. It has
been found that
11). Provide
the prone position
proper position
redistributes
to the client. A
ventilation from
prone position is
ventral to dorsal
recommended.
regions and
mobilizes
secretions.

12). Continous
activity leads to
fatigue. As a
result, it increases
the work of
breathing and the
body demands
more oxygen.
Rest helps to
mobilize energy
for more effective
breathing and
coughing.

13). Oxygen
saturation reading
below 90% may
be due to
hypoxia. It may
also cause
anaerobic cellular
 metabolism,
alteration in
12). Schedule consciousness,
daily activities in electrolyte
such a way that it imbalance and
will provide rest ultimate death.
periods between
activities. 14). Antibiotics
help to treat
underlying
microorganisms.
Bronchodilators
decrease
laboured
breathing and do
airway clearance.
Anti-anxiety drugs
decrease the
anxiety of the
13). Maintain
patient.
oxygen
saturation at 90% 15). Suctioning
or above. clears secretion
and gives a clear
way for breathing.

16). ARDS
requires the
involvement of a
multidisciplinary
team. Nurses
observe patients
all the time, so
any changes in
14). Administer respiration are
medications first observed by
according to the nursing
physician’s personnel. The
prescriptions. nurse must inform
(e.g., antibiotics, all the team
bronchodilators, members
steroids, and immediately
antianxiety about any change
 medications). for aggressive
intervention.

17). When the

patient could not
15). Do suction if cope up with the
required. medication and
other
intervention,
intubation and
mechanical
16). All the team ventilation is
members who recommended.
are involved in Mechanical
the care of the ventilation
patient must be provides
informed about adequate oxygen
the patients to the body.
respiratory
status.

17). Anticipate
any need for
intubation or
mechanical
ventilation.

Epistaxis
Assessment Nursing Planning Intervention Rationale Evaluation
Diagnosis

Subjective Risk for After 10 Dependent: "Goal met"

imbalanced minutes of
"I am 1). Administer 1). Biogesic is a After 10
fluid volume nursing
struggling wth related to interventions, Biogesic as pain reliever minutes of
severe ordered by the which help nursing
active fluid loss the client will
headache" as secondary to manifest physician promote interventions,
verbalized by comfort of the the client
epistaxis absence of Independent:
the patient nose bleeding patient manifested
2). Assist the absence of
• Fatigue 2). This
patient to sit nose bleeding
discourages
upright and further
lean forward
Objective bleeding.
Sitting forward
• Pain scale: 8 will help the
patient avoid
• BP: 140/80
swallowing
• Paleness blood which
can irritate his
• Epistaxis stomach

3). Pinching
3). Pinch the sends pressure
soft, to the bleeding
cartilaginous of point of the
the patient's nasal septum
nose and often
stops the flow
of blood

4). Applying ice

packs help
constrict blood
4). Apply cold vessels (which
compress to will slow the
the forehead bleeding) and
and the bridge promotes
of the patient's comfort
nose
5). To note
significant
 changes in the
patient's vital
signs
5). Monitor the 6). Hot and
patient's vital spicy foods
signs after 30 could dilate
minutes blood vessels
6). Instruct the in the nose
patient to which can
avoid hot and allow it to
spicy foods bleed

7). Plenty of
fluids
rehydrate the
patient from
7). Instruct the
the fluid loss of
patient to drink
his body
plenty of fluids
8). Incessant
and forecful
8). Teach ways nose blowing,
to to prevent or sneezing
epistaxis can exert a
(straining, high great deal of
attitude trauma on the
avoiding sensitive lining
forceful nose of the inner
blowibg, and nose and
nasal trauma) trigger a
nosebleed

9). A dry
environment
can irritate and
9). Provide
dry out nasal
humidification
membranes.
to avoid drying
This can cause
of the nasal
crusts that
passages
may itch and
bleed when
picked or
scratched.