ASSESSMENT NURSING BACKGROUND PLAN OF NURSING RATIONALE EVLATUATION

DIAGNOSIS KNOWLEDGE CARE/GOAL INTERVENTIONS

Ineffective Airway Infection of the After 8 hours of 1. Monitor 1. This is an Goal Partially met
Subjective: Clearance related lung nursing intervention respirations and indicative of
Dyspnea to decreased lung I the patient shall: breath sounds, respiratory The patient had
Objective: expansion noting rate and distress and/or maintained airway
secondary to fluid Inflammatory Maintain airway sounds (e.g., accumulation of patency. He can
accumulation
Adventitious Response initiated patency tachypnea, stridor, secretions. expectorate
breath sounds Expectorate/clear crackles and (Doenges, et. al. secretions and
(crackles and secretions readily wheezes). Nurses Pocket can verbalize
wheezes) Alveolar edema + Verbalize Guide 12th understanding of
Orthopnea exudates understanding of Edition. 2012. causes and
Restlessness formation causes and Page 81) therapeutic
therapeutic regimen. He
Laboratory and regimen 2. Evaluate 2. To determine demonstrated
Diagnostics: Alveoli & Demonstrate patients ability to protect behaviors to
Abnormal Respiratory behaviors to cough/gag reflex own airway. improve or
Arterial Blood bronchioles fill improve or and swallowing (Doenges, et. al. maintain clear
Gases: with serous maintain clear ability. Nurses Pocket airway. Patient
Compensated exudate, blood airway Guide 12th demonstrated
Respiratory cells, fibrin and Edition. 2012. reduction of
Acidosis with bacteria After 2 days of Page 378) congestion with
mild Hypoxia nursing interventions breath sounds
(November 23, the patient shall: 3. Elevate head of 2. To take clear, respirations
2017) Consolidation of Demonstrate bed and change advantage of noiseless,
Decreased the lungs absence or position every 2 gravity absence of
hemoglobin(116; reduction of hours and prn. decreasing cyanosis and
normal is 130- congestion with pressure on the normal oximetry.
170 g/L) 21 breath sounds diaphragm and
November 2017 clear, enhancing
Decreased respirations drainage
hematocrit noiseless, of/ventilation to
(0.35; normal is improved oxygen different lung
0.40-0.54) - exchange (e.g, segments.
21 November absence of (Doenges, et. al.
2017 cyanosis, arterial Nurses Pocket
blood gas/ pulse Guide 12th
oximetry results Edition. 2012.
within client Page 82)
norms.)
4. Encourage 4. Coughing is a
deep-breathing natural self-
and coughing cleaning
exercises. mechanism of the
airway and a
major means of
assisting the
airway cilia in
maintaining
patent airways.
(Doegenes, M.,
Jeffries &
Moorhouse M.
Nursing Care
Plans page 111.)

5. Increased fluid 5. Hydration can

intake to at least help liquefy
2000 ml/day within viscious
cardiac tolerance. secretions and
Encourage/ improve secretion
provide warm clearance.
versus cold liquids (Doegenes, M.,
as appropriate. Jeffries &
Provide Moorhouse M.
supplemental Nursing Care
humidification Plans page 111.)
such as nebulizer.

6. Administer Usually given

Expectorants later in course of
illness to clear
lung of exudates
and secretions.
(Doegenes, M.,
Jeffries &
Moorhouse M.
Nursing Care
Plans page 111.)