ASSESSMENT NURSING EXPECTED IMPLEMENTATION RATIONALE EVALUATION

DIAGNOSIS OUTCOME
SUBJECTIVE DATA: Ineffective Breathing At the end of the 1. Assess the patient’s 1. Assessing the rate Partially Met.
(Patient unable to Pattern related shift, the patient will respiration and depth of At the end of the
communicate, Exudative Pleural achieve an effective characteristics and breathing along with shift, the patient
presence of Effusion, breathing pattern as vital signs. O2 saturation, pulse, achieved an effective
Endotracheal Tube) Compromised Lung evidenced by a and blood pressure breathing pattern as
Expansion and Excess respiratory rate of 12- are necessary to evidenced by a
Fluid Buildup in the 20 bpm and oxygen monitor for changes respiratory rate of 12-
pleura secondary to saturation above 95%. or worsening in 20 bpm and oxygen
infection, respiratory status. saturation above 95%
inflammation, cardiac With the aid of a
disease, and ventilator.
OBJECTIVE DATA: pulmonary disease as 2. Review the 2. Understanding the
05/10/2023 0700H evidenced by patient’s underlying patient’s underlying
T- 36.3 C tachypnea, condition. condition is essential
PR- 75bpm desaturation with to providing
RR-28 bpm dyspnea without appropriate
BP- 130/42 mmHg ventilation support, interventions.
02 sat- 100% (on bilateral wheezes on
pressure control both lungs, 3. Administer 3. The patient may be
ventilator) Respiratory Acidosis medications as prescribed antibiotics
GCS- 3/15 on ABG and Pleural prescribed. to treat pneumonia or
Eye- 1 Fluid cytology of diuretics for
Verbal-1 Exudative pleural congestive heart
(endotracheal tube) effusion with failure and
Motor- 1 (No motor moderate bronchodilators as
response) inflammatory indicated.
RASS Score- -5 (No organizing pleuritis.
response to voice or
stimuli) 4. Elevate the
CXR- Bilateral patient’s Head of the 4. Elevating the head
wheezes all over the Bed. of the bed can
chest improve lung
ABG- on admission expansion and help
-pH- 7.16 open the airways
-PCO2-104 enabling air to pass
-PO2-55 through with less
-HCO3-26 obstruction making it
(RESPIRATORY easier to breathe.
ACIDOSIS) 5. Prepare for
PLEURAL FLUID surgery/procedure as 5. Depending on the
CYTOLOGY: ordered. cause, pleural
Exudative Pleural effusion may require
Effusion with placing a pleural
moderate drain or chest tube or
inflammatory performing
organizing pleuritis procedures like
pleurodesis.
Contraptions: 6. Administer oxygen
-Central Line Right therapy as 6. Providing
Internal Jugular Vein prescribed. supplemental oxygen
19/9/23 is essential to prevent
-Arterial Line G20 cellular hypoxia
Left Radial 17/9/23 caused by low
-NGT F12 Left oxygen secondary to
Nostril 17/9 ineffective breathing
-Endotracheal Tube patterns (non-
7.5mm 20/9 invasive ventilation
-IFC F16 2/8/23 or Mechanical
Ventilator).

ASSESSMENT NURSING EXPECTED IMPLEMENTATION RATIONALE EVALUATION

DIAGNOSIS OUTCOME
 SUBJECTIVE DATA: Impaired gas At the end of the shift 1.Assess the patient’s 1. Assessing the rate Partially met.
(Patient unable to exchange related to the patient will respiration and depth of At the end of the shift
communicate, decreased function of exhibit improved gas characteristics and breathing along with the patient exhibited
presence of lung tissue as exchange as vital signs. O2 saturation, pulse, improved gas
Endotracheal Tube) evidenced by evidenced by ABGs and blood pressure exchange as
decreasing GCS, within normal limits are necessary to evidenced by ABGs
tachypnea, dyspnea and able to maintain monitor for changes within normal limits
and abnormal ABGs- optimal gas exchange or worsening in and was able to
Respiratory Acidosis. as evidenced by respiratory status. maintain optimal gas
unlabored breathing exchange as
and respiratory rate evidenced by
within normal limits. unlabored breathing
and respiratory rate
within normal limits.
OBJECTIVE DATA: 2. Auscultate lung 2. An initial With the aid of a
05/10/2023 0700H sounds. assessment will help ventilator.
T- 36.3 C provide baseline
PR- 75bpm information and
RR-28 bpm ongoing assessments
BP- 130/42 mmHg will determine
02 sat- 100% (on changes in the
pressure control patient’s condition.
ventilator) Gas exchange is
GCS- 3/15 (from affected by shallow
12/15) and rapid breathing
GCS- 3/15 patterns. Note areas
Eye- 1 of diminished breath
Verbal-1 sounds or fremitus.
(endotracheal tube)
Motor- 1 (No motor
response) 3. Review laboratory 3. Arterial blood
RASS Score- -5 (No values and imaging gases (ABGs)
response to voice or results. measure oxygenation
stimuli) and acid-base
CXR- Bilateral balance in the blood
wheezes all over the which can help assess
chest the patient’s
ABG- on admission respiratory status and
-pH- 7.16 prevent respiratory
-PCO2-104 distress. Chest x-rays
-PO2-55 can help determine
-HCO3-26 the size and location
(RESPIRATORY of the pleural
ACIDOSIS) effusion.
NORMAL ABGs 4. Consider lateral
after hooked to the positioning. 4. Elevating the head
ventilator. of the bed to 45
pH-7.4 degrees and
PCO2-43 positioning the
HCO3-26 patient in a lateral
Normal ABG position has been
PLEURAL FLUID shown to increase O2
CYTOLOGY: saturation and
Exudative Pleural decrease respiratory
Effusion with rate in those with
moderate unilateral pleural
inflammatory effusions.
organizing pleuritis

(-) GROWTH
CULTURES (blood,
Tracheal aspirate, 5. Administer oxygen
urine, and pleural therapy as 5. Providing
fluid) prescribed. supplemental oxygen
 is essential to prevent
Contraptions: cellular hypoxia
-Central Line Right caused by low
Internal Jugular Vein oxygen secondary to
19/9/23 ineffective breathing
-Arterial Line G20 patterns (non-
Left Radial 17/9/23 invasive ventilation
-NGT F12 Left or Mechanical
Nostril 17/9 Ventilator).
-Endotracheal Tube 6. Administer
7.5mm 20/9 medications as 6. The patient may be
-IFC F16 2/8/23 prescribed. prescribed antibiotics
to treat pneumonia or
diuretics for
congestive heart
failure and
bronchodilators as
indicated.

7. Prepare the patient

for indicated 7. Surgical
procedures. interventions like
thoracentesis,
pleurodesis, or chest
tube insertion may be
indicated if the
patient’s condition
worsens.
ASSESSMENT NURSING EXPECTED IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS OUTCOME
SUBJECTIVE DATA: Risk for infection At the end of the shift 1.Assess vital signs. 1. This will help Met. At the end of the
(Patient unable to related to pooling of the patient will show identify shift
communicate, fluid in the lung no signs of infection. physiological the patient showed
presence of space related to changes that occur no signs of infection
Endotracheal Tube) compromised from with infection. and had negative
underlying disease. bacterial growths in
Sputum and pleural
fluid.
OBJECTIVE DATA: 2. Keep an eye on the 2. A rising white
05/10/2023 0700H white blood cell blood cell count
T- 36.3 C count (WBC) of the reflects the body’s
PR- 75bpm patient. attempts to fight
RR-28 bpm infections. On the
BP- 130/42 mmHg other hand, a very
02 sat- 100% (on low WBC count could
pressure control also suggest a high
ventilator) risk of infection.
GCS- 3/15
Eye- 1 3. Closely monitor 3. Sputum that is
Verbal-1 the colour and thick, yellow, green,
(endotracheal tube) characteristics of the or tan coloured could
Motor- 1 (No motor patient’s respiratory suggest infection. It
response) secretions. is possible that a
RASS Score- -5 (No sputum culture will
response to voice or be required by the
stimuli) attending physician.

CXR- Bilateral
wheezes all over the
chest
ABG- on admission 4. Consider the 4. Malnutrition has
-pH- 7.16 patient’s dietary an impact on the
-PCO2-104 requirements. Weight development of
-PO2-55 and laboratory immune cells, which
-HCO3-26 parameters, such as are essential for
(RESPIRATORY serum albumin, fighting off
ACIDOSIS) should be monitored. infections.
NORMAL ABGs
after hooked to the 5. Wash hands 5. Washing
ventilator. frequently or minimizes the chance
pH-7.4 performs hand of infections
PCO2-43 hygiene before spreading from one
HCO3-26 contacting the part of the body to
Normal ABG patient. another.
PLEURAL FLUID Handwashing
CYTOLOGY: frequently is
Exudative Pleural intended to break the
Effusion with infection cycle.
moderate
inflammatory
organizing pleuritis

(-) GROWTH
CULTURES (blood,
Tracheal aspirate,
urine, and pleural
fluid)

Medical History:
-Ischemic Heart
Disease
-Congestive Heart
Failure
-Pulmonary Edema
-Hypertension
Contraptions:
-Central Line Right
Internal Jugular Vein
19/9/23
-Arterial Line G20
Left Radial 17/9/23
-NGT F12 Left
Nostril 17/9
-Endotracheal Tube
7.5mm 20/9
-IFC F16 2/8/23

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physical-side-effects/fluid-around-lungs-or-malignant-pleural-effusion
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