Assessment Nursing Planning Intervention Rationale Evaluation

Diagnosis
Long Term Short Term Selected Implemented

Subjective: Ineffective During the Following an ♦ Assess ♦ Assessed ♦ Provides a At the end of
“Nahihirapan airway client’s stay 8-hr nursing the shift, the
clearance at the intervention, respiratory respiratory basis for client was
sya huminga
dahil sa related to hospital he the client will function, rate. evaluating able to
plema.” as increased will be able to be able to: display
verbalized by production of maintain e.g., adequacy patency of
 Achieve
the client’s bronchial patent airway breath of airway as
wife. secretions as evidenced successful manifested
secondary to by: progressiv
sounds, ♦ Noted ventilation by:
Objective: fluid shift to  Independe rate, and chest .  Successful
extravascular e T-piece
 On nce from use of movement T-piece
compartment weaning of
endotrach . oxygen ♦ Use of weaning
accessory ; use of
(5-15-30-
eal tube and muscles accessory by
45-60 accessory
attached ventilatory and muscles of achieving
mins) muscles
to a support secretion respiration the goal of
during
mechanica characteri may occur completing
 Sustain respiration
l ventilator  Normal stics and in 60mins.
respiratory .
with respiration amount. response
rate within
increasing as to  Client’s
normal
evidenced ♦ Auscultate ineffective respiratory
duration of range: RR-
by d breath ventilation rate is
T-piece 12-20
absence of sounds; . within
weaning cpm.
dyspnea noted normal
(5, 15, 30,
and areas with ♦ Crackles range: RR-
45, 60  Display
adventitio presence indicate
mins.) decreasing
Assessment Nursing Planning Intervention Rationale Evaluation
Diagnosis
Long Term Short Term Selected Implemented

 Abnormal us breath amount of of accumulati 18 bpm.

breath sounds secretions adventitio on of
(wet (less than us sounds. secretions  Secretions
sounds:
crackles). 40cc). and decreased
wet
♦ Document in amount
crackles inability to
 Normal  Allay ed clear from 40 cc
on (R) and
breathing restless- respiratory airways. to 30 cc
(L) lung ♦ Position
pattern: ness. secretions: collected
bases. patient in
RR = 12- character ♦ Expectorat in an 8-hr
semi- or
 Dyspnea; 20 cpm and ions may shift
high-
use of amount of be (Continue
Fowler’s
 Absence of sputum. different assessmen
accessory position.
bronchial when t of
muscles
secretions ♦ Maintained
for ♦ Assess secretions respiratory
patient on are very status and
respiration airway
 Normal moderate
: elevated patency. thick. suctioning
chest x- high back
shoulders. as
ray results rest. needed).
♦ Positioning
 Increase in
 Allay ♦ Suction as helps
respiratory  Client’s
restless- needed ♦ Checked maximize
rate: RR- restlessnes
ness when for lung
25 cpm s was
patient is obstructio expansion.
alleviated
Assessment Nursing Planning Intervention Rationale Evaluation
Diagnosis
Long Term Short Term Selected Implemented

 Secretion experienci ns: and

characteri ng accumulati remained
♦ To
stics: difficulty on of calm.
maintain
yellowish of secretions.
adequate
in color breathing,
airway
♦ Suctioned
and 40 ml limiting
patency.
duration of patient
in amount
suction to limited to
collected ♦ Duration
15 sec or 5-sec
in an 8-hr should be
less. duration.
shift. limited to
reduce
 Chest x- ♦ Administer
hazard of
ray reports medicatio
hypoxia,
haziness ns as
damage
on both indicated:
airway
lower Bronchodil
mucosa
hemithora ators.
and impair
x taken on
cilia
Septembe
action.
r 7, 2006.

 Restless ♦ Increases
lumen size
Assessment Nursing Planning Intervention Rationale Evaluation
Diagnosis
Long Term Short Term Selected Implemented

of the
tracheobro
nchial
tree, thus
decreasing
resistance
to airflow
and
improving
oxygen
delivery.

Subjective: Anticipatory During the Following an ♦ Encourage ♦ Explained ♦ Active At the end of
“Malungkot grieving patient’s stay 8-hr nursing the shift, the
related to at the management, active every participati client was
siya.” As
verbalized by loss of hospital, he the client will participati procedure on able to:
the client’s physiological will be able to be able to:  Have an
well-being appropriately on of done to maintains
wife.  Develop
secondary to progress improved
patient in the patient patient
progressive through awareness
Objective: awareness
debilitating grieving care and and family. independe
which
 With disease. process as as
treatment nce and
evidenced by: leads to
episodes ♦ Approache manifested
decisions. control.
 Client therapeuti
of d the by
grieving c crying.
occasional ♦ Nurse family and ♦ Frequent therapeuti
Assessment Nursing Planning Intervention Rationale Evaluation
Diagnosis
Long Term Short Term Selected Implemented

crying process  Cooperate should establishe contact c crying

progressin with visit the d rapport helps (continue
 Sadness g from family with the reduce providing
treatment
phase 2 procedure frequently patient’s feelings of emotional
 Loss of
(feeling) to s. and family. isolation support).
appetite
phase 3 provide and
(dealing)  Remain physical abandonm  Participate
 Fatigue ♦ Sat with
as calm. contact as ent. d in
patient
theorized appropriat treatment
 General
 Improve and family
by e. procedures
discomfort
sleeping quietly ♦ This allows
Rodebaug .
pattern and used for
 Uncoopera ♦ Allow
h et. al.
(uninterru active emotional  Remained
tive with periods of
pted sleep listening expression calm: allay
procedure  Developin crying and
of at least as . restlessnes
s. g expression
2 hours). therapeuti s.
awareness of
 Restless c
which sadness.
communic  Sleeping
leads to
 Mostly flat ation. pattern
therapeuti
affect ♦ Patient improved:
c crying.
♦ Encourage slept for 2
may feel
 Changes ♦ Encourage d patient hours
 Cooperate supported
in sleeping verbalizati and family (night
with in
Assessment Nursing Planning Intervention Rationale Evaluation
Diagnosis
Long Term Short Term Selected Implemented

pattern: treatment on of to express expression shift).

interrupte procedure thoughts/c their of feelings
d sleep s. oncerns thoughts by the
every hour and accept and understan
at night  Remain expression concerns ding that
and fully calm. s of by asking deep and
awake sadness, open- often
 Uninterrup
during anger, ended conflicting
ted sleep
daytime. rejection. questions emotions
at least 6
(e.g. “Tell are normal
 Loss of hours.
me how and
independe you’re experience
 Patient,
nce: coping.”). d by
with his
functional others in
family, will ♦ Arrange
level IV. this
seek social care to

support provide for difficult

♦ Maintained
and uninterrup situation.
a relaxed,
resources ted
calm, non- ♦ To assist
appropriat periods for
stimulatin client to
ely. rest, for
g establish
especially
environme optimal
allowing
nt. sleep/rest
Assessment Nursing Planning Intervention Rationale Evaluation
Diagnosis
Long Term Short Term Selected Implemented

for longer
periods of
sleep at
night
when
possible.
Do as pattern.
much care
as possible
without
waking the
client.