Cues Nursing Analysis Goal and Interventions Rationale Evaluation

Diagnosis Objectives

Subjective: Ineffective Increased Goal: After an Goal met.

- The client Airway amount and 8-hour shift,
verbalized, Clearance viscosity of the client’s
“Nahihiripan related to secretions secretions
talaga ako Secretions in and/or inability would be
huminga lalo na the bronchi to clear lessened.
nung una kong secretions
punta dito sa through the Objectives: 1. The client
hospital” normal cough 1. After 30 was able to
-“1 bottle lang mechanism minutes, the expel mucous.
nauubas kong may lead to client will be
tubig sa isang pooling of able to expel DEVELOPMENT
araw” secretions in mucous by: AL The patient needs to
lower airways. a. Doing a. Teach the cough to be able to
Pooling of proper client proper remove the mucus
Objective: secretions leads coughing coughing (p530,
- Adventitious to infection and technique technique. Smeltzer,Medical-
Breath Sounds inadequate gas surgical Nursing vol.
(Rales) exchange. 1)
-Cough with
phlegm (p229, SUPPLEMENTAL
-Pale Nettina,Manual b.Apply Chest Chest physiotherapy
of nursing b. Applying Percussion to is important in
practice) Chest the Client. loosening and
percussion mobilizing
secretions.
Indications for chest
physiotherapy
include sputum
retention not
responsive to
spontaneous or
directed cough,
abnormal chest x-ray
 findings consistent
with infiltrates or
deterioration in
oxygentaion. (p530,
SUPPLEMENTAL Smeltzer,Medical-
c. Position the surgical Nursing vol.
c. Chest client for 1)
Drainage Postural
Drainage.
The patient is placed
in the proper
position to drain the
involved lung
FACILITATIVE segments. (p530,
d. Administrat d. Administer Smeltzer,Medical-
ion of Antibiotics as surgical Nursing vol.
drugs ordered 1) 2. The client
was able to
maintain
2. The client For infections. adequate
will be able to (NANDA) hydration.
maintain
adequate SUPPLEMENTAL
hydration by: a. Increase the
a. Increasing number of fluid
oral fluid being drunk by
intake the patient. Efficiency
The time,
An increased materials, and
respiratory rate human
leads to an increase resources were
in insensible fluid used
loss during economically
exhalation and can
lead to dehydration.
(p530, Adequacy
SUPPLEMENTAL Smeltzer,Medical- The numbers of
b. Regulate the surgical Nursing vol. interventions
b. Regulating IV fluid as 1) were sufficient.
intravenou ordered.
s Fluid. Appropriateness
The
interventions
were suitable to
the client’s
Administration of this situation.
fluid generally
causes dilution of Acceptability
plasma solute The
concentration and interventions,
forces water setting, and
movement into cells timetable were
to reestablish realistic to the
intracellular and client’s
extra cellular situation.
equilibrium; cells
then expand or
swell.
(p84,Nettina,Manual
of nursing practice)