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Cues Nursing Diagnosis Rationale Desired Outcome Nursing Interventions Justification Evaluation

After 3 days of nurse- After 3 days of nurse-


Objective: client interaction, the client interaction, the
Respiratory client will be able to: Independent: client was able to:
rate Establish baseline To identify
30breaths/min Maintain vital signs, alterations in Baseline vital
ute patent airway. specifically respiratory signs: T- 36.8; RR-
Whitish phlegm Verbalize respiratory rate status 25breaths/min;
approximately causative CR-
10cc per factors that 76beats/minute;C
expectoration lead to Auscultate lung To assess area R-
Clear nasal chronic sounds on of consolidation 76beats/minute;
discharge maxillary anterior and To facilitate BP
Anterior chest sinusitis posterior thorax breathing 100/70mmHg.
heaviness rated Appropriately Elevate clients No adventitious
as 4/10. cough out head; semi- To mobilize sounds noted on
secretions fowlers position secretions anterior and
Subjective: using Give chest posterior thorax
Ga ubo-ubo coughing physiotherapy Able to tolerate
ako gamay kag exercises To prevent 45o position
daw okay Lessened Health teachings: reoccurrence of
naman akon bronchial and Health teachings infections Able to cough out
sip-on. Ang nasal about secretions
dughan ko daw discharges environmental
bug-at lang Able to factors such as To
akon practice allergens that appropriately Able to
pamatyagan. appropriate could contribute cough out enumerate
deep to sinusitis secretions environmental
breathing Teach patient to To encourage factors that could
exercises perform proper lung expansion contribute to
Decreased coughing chronic maxillary
feeling of techniques sinusitis such as
anterior chest Teach how to do To promote dusts,
heaviness appropriate deep wellness pollens,bacteria,
breathing Avoid allergic strong odors.
exercises reactions Able to perform
half cough
Therapeutic
Encourage Help loosens Able to do deep
adequate rest phlegm, prevent breathing
Provide a clean dehydration exercises
and allergen free
environment Aids in
Increase fluid preventing
intake bronchospasm Verbalized to
and liquefy have adequate
Collaborative secretions rest
Administer Does not
medications as manifest signs
prescribed; and symptoms of
expectorants, allergic reactions
bronchodilators. Verbalized to
regularly drink 8-
10 glasses of
water a day

Does not
To supply manifest signs
oxygen and symptoms of
demand, and to bronchial spasm.
maintain good Expectorate to
nasal hygiene. clear whitish
Provide sputum
recommended approximately
treatments: 5cc. (better prior
oxygen support, to admission)
nasal sprays. Patent bilateral
nares, verbalized
to have lessened
nasal discharge
Respiratory rate
of 24 breaths per
minute,
unlabored.
Verbalized
decreased feeling
of anterior chest
heaviness rated
as 3/10

No sign of oxygen
deprivation.
Maintains patent
nares and good
nasal hygiene.

General Evaluation:
After giving nursing interventions, goals were met. Client does not manifest any sign of pulmonary distress, has patent bilateral nares, able to perform deep breathing
exercises, cough out decreased bronchial secretions appropriately using half cough, verbalized lessened nasal discharge and feeling of anterior chest heaviness rated as 3/10.
Nursing Diagnosis: Risk for acute pain related to localized accumulation of fluid in maxillary sinus secondary to sinusitis
Cues Goals of care Nursing Interventions Rationale Evaluation Patients response
Within 8 hours of clinical Independent:
Objective: duty, patient will be able to: Assess respiratory status To check for nasal DONE Patent bilateral nares.
Medical impression Verbalized no pain in congestion and nasal
of chronic maxillary maxillary sinus patency.
sinusitis. Identify presence of pain To give appropriate DONE No pain.
analgesics, and
Subjective: determine progression
Wala man sakit pero of pain
daw bug-at lang bala Transilluminate maxillary To determine severity of DONE Negative. Red glow shines on maxillary
ang pamatyagan sa sinus accumulation of fluid area.
dalum sang mga
mata ko Health teachings:
Ask client to report pain. To give prompt DONE No pain.
medication treatment
Teach how to do appropriate To promote lung DONE Able to perform proper deep breathing
deep breathing exercises expansion exercises

Therapeutic
Provide an allergen free To prevent allergic DONE Does not manifest nasal stuffiness, and
environment responses that could other allergic responses.
trigger sinusitis
Teach about proper blowing To equalize ear pressure DONE Verbalized to practice blowing of nose
of nose with bilateral nares open.

Collaborative:
Give analgesics as ordered. To prevent pain NOT DONE Not applicable

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