ASSESSME NURSING NURSING OBJECTIV INTERVENTION RATIONALE EVALUATIO

NT DIAGNOS ANALYSI ES N
IS S
SUBJECTIV Ineffective pathogen Short Term - Establish rapport - Building rapport Short Term
E: airway ↓ Goal: aims to get the Goal: Met
clearance inflammato (to be client’s trust and The patient has
“Nahihirapan related to ry response achieved cooperation to shown
po akong Excessive ↓ within 48 render an effective improvements
huminga” as mucus as alveolar hours) The . nursing care. on her:
verbalize by evidenced infiltration patient will - Identify client - Persons with - absence
the patient by DOB ↓ maintain a populations at risk. impaired ciliary of
exudate patent function those audible
OBJECTIVE formation airway, as with excessive or wheezin
: ↓ demonstrated abnormal mucus g
- DOB alveolar by the production those - improve
- Fatigu consolidati absence of with impaired d breath
e on audible cough; those with sounds
- Coug ↓ wheezing, swallowing - decreas
h impaired improved abnormalities; and ed
Vital Signs: gas breath those who are all respirat
T- 36.6 exchange sounds, and at risk for ory rate
PR- 71bpm ↓ decreased problems with the
RR- 40bpm dyspnea respiratory maintenance of Long Term
BP- ↓ rate to within - Assess level of open airways. Goal: Met
110/70mmHg ineffective the normal consciousness/cogn The patient
O2sat: 84% airway range for ition and ability to demonstrates on
clearance emphysema protect own airway - This information her own:
pt. (25 is essential for
breaths per - proper
identifying coughin
minute). potential for g
airway problems, techniq
Long Term providing baseline
Goal: - Monitor level of care ue
(to be respirations and needed, and - deep
achieved breath sounds, influencing choice breathin
within 1 noting rate and of interventions g
week) The sounds (e.g., - indicative of exercise
patient will tachypnea, stridor, respiratory s
independentl crackles, or distress and/or
y perform wheezes) accumulation of
effective - Evaluate client’s secretions. Health
airway cough/gag reflex, Teaching:
clearance amount and type of
techniques, secretions, and - to determine 1. Wearing of
such as swallowing ability. ability to protect mask can help
proper - Position head own airway. prevent transfer
coughing appropriately for of bacteria.
technique age and condition 2. Advice the
and deep patient to finish
breathing - to open or the medication
exercises, to - Suction nose, maintain open prescribed by
maintain mouth, and trachea airway in an at- the physician
optimal prn using a correct- rest or especially
respiratory size catheter and compromised antibiotics to
function. suction timing. individual. prevent
- to clear airway antibiotic
when excessive or resistance.
viscous secretions
- Insert oral airway are blocking
when needed airway or client is
unable to swallow
or cough
effectively
- to maintain
anatomical
 position of tongue
and natural
airway, especially
- Elevate head of when
bed, encourage tongue/laryngeal
early ambulation, or edema or thick
change client’s secretions may
position every 2 hr block airway

- to take advantage
of gravity
decreasing
- Exercise diligence pressure on the
in providing oral diaphragm and
hygiene and enhancing
keeping oral drainage
mucosa hydrated. of/ventilation to
different lung
segments.

- Airways can be
obstructed by
substances such as
blood or thickened
secretions. These
- Assist with can be managed
appropriate testing by strict attention
(e.g., pulmonary to good oral
function or sleep hygiene,
studies) especially in the
- Assist with client who is
unable to provide
 procedures (e.g., that for self.
bronchoscopy or
tracheostomy)
- to identify
causative/precipita
ting factors.

- to clear/maintain
open airway.

ASSESSME NURSING NURSING OBJECTIV INTERVENTION RATIONALE EVALUATI

NT DIAGNOS ANALYSI ES ON
IS S
SUBJECTIV Ineffective Short Term - Establish rapport - Building rapport Short Term
E: breathing chronic Goal: aims to get the Goal: Met
pattern airway (to be client’s trust and The patient
“Nahihirapan related to inflammati achieved cooperation to render has a reduce
po akong reduced on and within 48 effective nursing respiratory
huminga” as pulmonary alveolar hours) The care. rate from 33
verbalized by complacenc destruction patient will - Assist in treatment to 25 breaths
the patient y ↓ achieve a of underlying per minute.
loss of reduction in conditions,
OBJECTIV elasticity in respiratory administering Long Term
E: alveoli and rate from 33 medications and Goal: Met
- cough airways to 25 breaths therapies as The patient
- DOB ↓ per minute. ordered. has shown
- chest reduced - Administer oxygen - for management of knowledge
pain pulmonary Long Term at the lowest underlying related to
compliance Goal: concentration pulmonary condition, asthma
 ↓ (to be indicated and respiratory distress, medications
increased achieved prescribed or cyanosis. and therapies
Vital Signs: airway within 1 respiratory to prevent
T- 36.6 resistance week) The medications exacerbations
PR- 71bpm ↓ patient will - Suction airway, as - to clear secretions .
RR- 40bpm demonstrate needed
ineffective
BP- effective use - Assist with
breathing
110/70mmHg of prescribed bronchoscopy or Health
patter
O2sat: 84% medications chest tube insertion Teaching:
and therapies as indicated.
to manage - Elevate the head of 1. Advice the
COPD the bed and/or have pt. about the
symptoms the client sit up in a lifestyle
and prevent chair, as changes that
exacerbation appropriate she will
s. - Direct client in - to promote encounter
breathing efforts as physiological and related to
needed. Encourage psychological ease of asthma:
slower and deeper maximal inspiration
- to assist client in - 1L of water
respirations and use intake per day
of the pursed-lip “taking control” of
technique the situation, - small
- Monitor pulse especially when frequent meal
oximetry, as condition is
associated with - high
indicated
anxiety and air protein, low
- Maintain a calm
hunger. carb diet
attitude while
dealing with the
client and signifi
cant other(s) - to verify
- Assist the client in maintenance/improve
the use of ment in O 2
relaxation saturation
- to limit the level of
 techniques. anxiety.
- Deal with
fear/anxiety that
may be present.
(Refer to NDs Fear;
Anxiety.)
- Encourage a
position of comfort.
Reposition the
client frequently if
immobility is a
factor - Promotes more
- Coach client in effective breathing
effective coughing and airway
techniques. Place in management,
appropriate position especially when
for clearing client is guarding, as
airways. Splint the might occur with
rib cage during chest, rib cage, or
deep-breathing abdominal injuries or
exercises/cough, if surgeries.
indicated
- Medicate with
analgesics, as - to promote deeper
appropriate, respiration and
- Encourage cough.
ambulation/exercise
, as individually
indicated - to prevent onset or
reduce severity of
respiratory
complications and to
- Provide/encourage improve respiratory
 use of adjuncts, muscle strength.
such as incentive
spirometer
- to facilitate deeper
respiratory effort.

- Supervise the use

of
respirator/diaphrag
- when neuromuscular
matic stimulator,
impairment is
rocking bed, apnea
present.
monitor, and so
forth
- Ascertain that the
client possesses and
properly operates - when obstructive
continuous positive sleep apnea is
airway pressure causing breathing
(CPAP) machine problems
- Maintain
emergency
equipment in - when ventilatory
readily accessible support might be
location and needed.
include age-/size-
appropriate
endotracheal/trach
tubes (e.g., infant,
child, adolescent, or
adult)
 .

ASSESSMENT NURSING NURSING OBJECTIV INTERVENTION RATIONALE EVALUATIO

DIAGNOSI ANALYSI ES N
S S
SUBJECTIVE: Impaired impaired Short Term - Establish rapport - Building Short Term
gas alveolar- Goal: rapport aims Goal: Partially
“Nahihirapan po exchange capillary After 4-5 hrs to get the Met
akong huminga” related to membrane of nursing client’s trust The patient
as verbalized by impaired ↓ intervention and shows sign of
the patient alveolar- alveolar the patient cooperation to normal
capillary inflammati will be able to render an breathing
OBJECTIVE: membrane on return a - Elevate the head of effective pattern:
related to ↓ normal the bed and position nursing care. - reduce
- capillary hypoxemia breathing - Elevation or tachypn
increases the client
return (5 pattern. upright ea
the appropriately
secs) position - reduce
thickness of
- SOB Long Term facilitates wheezin
alveolar –
- DOB Goal: respiratory g sound
capillary
- Wheezin After 1 week function by
membrane
g of health gravity; Long Term
- Tachypn ↓
teaching the however, a Goal: Met
ea impaired - Provide airway
patient will client in The patient
gas adjuncts and
exhibit severe show
Vital Signs: exchange suction, as indicated
understanding distress will understanding
T- 36.6 ↓ on her seek a on how to
PR- 71bpm hypoxia condition and position of manage the
RR- 40bpm on how comfort. symptoms
BP- properly properly by:
110/70mmHg address its
O2sat: 84% symptoms. - proper
- to clear or deep-
maintain open breathin
- Encourage frequent airway, when
position changes g
client is techniq
and deep-breathing unable to
and coughing ue
clear - proper
exercises. Use secretions, or
incentive coughin
to improve g
spirometer, chest gas diffusion
physiotherapy, and techniq
when client is ue
intermittent showing
positive-pressure desaturation
breathing, as of oxygen by
indicated. oximetry Health
- Provide Teaching:
supplemental
oxygen at lowest - This promotes 1. Educate
concentration optimal chest about proper
indicated by expansion, deep-breathing
laboratory results mobilization technique.
and client symptoms of secretions, 2. Educate
or situation and oxygen proper
- Monitor and adjust diffusion. coughing
ventilator settings technique.
(e.g., FIO 2, tidal
volume, inspiratory 3. Advice the
and expiratory ratio, patient about
sigh, positive end– the limit in fluid
expiratory pressure) intake.
as indicated when
mechanical support
 is being used

- Maintain adequate - The mode of

fluid intake ventilation
(volume or
pressure) and
ventilator
settings are
determined by
the specific
- Use sedation needs of the
judiciously client, which
are
determined by
- Encourage adequate clinical
rest and limit evaluation
activities to within and blood gas
client tolerance. parameters.
Promote a calm,
restful environment
- for
- Administer mobilization
medications as of secretions,
indicated (e.g., but avoid
inhaled and fluid overload
systemic that may
glucocorticosteroids, increase
antibiotics, pulmonary
bronchodilators, congestion.
methylxanthines,
antitussives/mucolyt
ics, and - to avoid
vasodilators). depressant
 effects on
respiratory
- Monitor and instruct functioning
client in therapeutic
and adverse effects
as well as - This helps
interactions of drug limit oxygen
therapy needs and
- Keep environment consumption.
allergen and
pollutant free

- Pharmacologi
cal agents are
varied,
specific to the
client, but
generally
used to
prevent and
control
symptoms,
reduce
frequency and
severity of
exacerbations,
and improve
exercise
tolerance.
- to reduce
irritant effect
of dust and
chemicals on
airways.