ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:
(none)
Objective:
Weak &
restess
Irrtabe
(+)nasa
farng and
(+) use of
accessory
musces
Wth DOB and
(+) wheezes
(+)
productve
cough - yeow
n coor
warm, fushed
skn
(+)Tachypnea
and
(+)Tachycard
a
Wth changes
Ineffectve
arway
cearance r/t
accumuaton
of
tracheobronc
ha
secretons
SHORT TERM:
After 3-4 hours
of NI, pt.s SO
w be abe to
demonstrate
mprove arway
cearance as
evdenced by
reducton of
congeston wth
breath sounds
cear and RR
mprove
LONG TERM:
After 2-3 days of
NI, pt. w be
abe to estabsh
and mantan
arway patency.
1. Estabsh Rapport
2. Montor and record
vta sgns
3. Note RR, use of
accessory musces
& pursed p
breathng
4. Evauate cents
cough/gag refex
and swaowng
abty
5. Auscutate breath
sounds, note areas
of
decreased/adventt
ous breath sounds
6. Eevate head of bed
and encourage
frequent poston
changes.
7. Keep back dry and
oosen cothng
8. Instruct the SO to
ncrease cents
ora fud ntake to
at east 2000
m/day wthn eve
of cardac
1. To gan pts
trust
2. To obtan
basene data
3. To evauate
degree of
compromse
4. To determne
abty to
protect own
arway
5. To ascertan
status and note
progress or
compcatons
6. To promote
maxma
nspraton,
enhance
expectoraton of
secretons n
order to
mprove
ventaton
7. To promote
comfort and
adequate
ventaton
8. To hep quefy
the secretons
SHORT TERM:
After 3-4 hours
of NI, pt. sha
have
demonstrated
mprove arway
cearance as
evdenced by
reducton of
congeston wth
breath sounds
cear and RR
mprove
LONG TERM:
After 2-3 days
of NI, pt. sha
have
estabshed and
mantaned
arway patency.
n rate,
rhythm and
depth of
breathng
Wth changes
n rate,
rhythm and
depth of
breathng
Vta sgns
(RR - 54;
HR - 104;
Temp- ;
BP- )
toerance.
9. Encourage deep
breathng exercses
and coughng
exercses
10.Encourage
adequate rest and
mt actvtes to
wthn cent
toerance.
11.Fx bed nens
12.Gve expectorants
and bronchodators
as ordered.
13.Admnster oxygen
therapy and other
medcatons as
ordered.
14.Keep envronment
aergen-free
9. For dranage of
secretons
10.Rest w
prevent fatgue
and decrease
oxygen
demands for
metaboc
demands
11.To promote
comfort
12.To further
mobze
secretons
13.To cear arway
when secretons
are bockng the
arway ndcated
to ncrease
oxygen
saturaton.
14.To reduce
rrtant effects
on arway