ASSESSMENT NURSING NURSING OBJECTIVES INTERVENTION RATIONALE EVALUATION

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

- Elevate head of bed, - to take advantage of

encourage early gravity decreasing
 ambulation, or change pressure on the
client’s position every 2 diaphragm and
hr enhancing drainage
of/ventilation to
different lung
segments.

- Airways can be
- Exercise diligence in
providing oral hygiene
and keeping oral
mucosa hydrated.
obstructed by
substances such as
blood or thickened
secretions. These can
be managed by strict
attention to good oral
hygiene, especially in
the client who is
unable to provide that
for self.

- to identify
- Assist with appropriate causative/precipitating
testing (e.g., pulmonary factors.
function or sleep
studies)
- Assist with procedures
(e.g., bronchoscopy or - to clear/maintain open
tracheostomy) airway.

ASSESSMENT NURSING NURSING OBJECTIVES INTERVENTION RATIONALE EVALUATION

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

- to prevent onset or reduce

severity of respiratory
 - Provide/encourage use complications and to
of adjuncts, such as improve respiratory
incentive spirometer muscle strength.

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

.
ASSESSMENT NURSING NURSING OBJECTIVES INTERVENTION RATIONALE EVALUATION
DIAGNOSIS ANALYSIS
SUBJECTIVE: Acute Pain Atherosclerosis Short Term Goal: - Establish rapport - Building rapport aims Short Term Goal: Met
“nararanasan ko related to Development After 3 hours of nursing to get the client’s trust After nursing intervention the
yung pag sakit nang decreased intervention The patient and cooperation to patient report a reduction in the
aking dibdib pag myocardial blood Progression of will report a reduction in render an effective frequency and intensity of
ako’y napapagod” flow secondary to Atherosclerosis the frequency and nursing care. angina episodes as evidenced
as vervalized by the atherosclerosis as intensity of angina by a pain scale decrease from
patient evidenced by Ischemia episodes as evidenced by a 7/10 to 3/10
angina pain scale decrease from - Administer prescribed - Aspirin may be given
OBJECTIVE: Angina 7/10 to 3/10. medications that to reduce the ability of Long Term Goal: Partially
Long Term Goal: alleviate the the blood to clot, so Met
- Angina Acute pain After 1 week of nursing that the blood flows After the nursing intervention
symptoms of angina.
- Pain scale 7 intervention the patient easier through the the patient will indicated of
out of 10 will participate in a narrowed arteries. increased activity tolerance,
- Facial structured exercise Nitrates may be given but the patient has not yet fully
grimace program, gradually to relax the blood demonstrated the ability to
increasing activity vessels. Other perform all daily activities
Vital Signs: tolerance and medications that help without triggering angina.
T- 36.6 demonstrating the ability treat angina include
PR- 71bpm to perform daily activities anti-cholesterol drugs
RR- 40bpm without triggering angina. (e.g. statin), beta Health Teaching:
BP- 110/70mmHg blockers, calcium
O2sat: 84% channel blockers, and 1. Educate the patient on
Ranolazine. her condition.
2. Advice the patient to
take her prescribed
medication

- Assess the patient’s - To monitor

vital signs and
characteristics of pain
at least 30 minutes
after administration of
medication.
effectiveness of
medical treatment for
the relief of angina.
The time of
monitoring of vital
 signs may depend on
the peak time of the
drug administered.

- Elevate the head of

the bed if the patient - To increase the
is short of breath. oxygen level
Administer
supplemental oxygen,
as prescribed.
Discontinue if SpO2
level is above the
target range, or as
ordered by the
physician.
- Place the patient in
complete bed rest
during angina attacks.
Educate patient on
stress management, - Stress causes a
deep breathing persistent increase in
exercises, and cortisol levels, which
relaxation techniques. has been linked to
people with cardiac
issues. The effects of
stress are likely to
increase myocardial
workload.