CUES NURSING OUTCOME INTERVENTION RATIONALE EVALUATION

DIAGNOSIS S
Subjective: Ineffective At the end of w 1.Auscultate chest 1. Presence of
Breathing days nursing characters of breath sounds
Objective: Pattern r/t interventions ,pt breath sounds and indicate
>Pursed-lip overproduction will be able to: presence of recreations
breathing of mucus secretions
secondary to Establish a 2. Different
>Labored pneumonia normal effective 2.Note type of breathing
Breathing respiratory breathing pattern: patterns indicate
pattern;RR- 16- tachypnea cheyne- different areas
>RR:36cpm 20 cpm stroke,others of concern
>Use a accessory irregular patterns
Muscles for Be free from 3. different
breathing cyanosis and 3. Review chest x- illnesses that
>crackles heard other symptoms rays as indicated cause condition
upon auscultation of hypoxia for severity of has different
>fatigue acute/chronic way of
>Diaphoresis illnesses intervention
>Restlessness
>DOB 4.Give 02 4. To provide 02
>Nasal Flaring inhalation as supplementation
>Dyspnea ordered 5. promotes lung
>Cyanosis on (collaborative) expansion
fingers 5. Elevate head of 6. to reduce
the bed degree of
6.encourage additional strain
position of 7. Other sources
comfort of pain will add
7.avoid more to
overeating/gas- respiratory
forming foods that distress
may cause abdm’l 8. To regain
distention energy
8.Encourage 9. promotes
adequate rest excretion of
periods secretion
9.Resposition 10. to dilate
client frequently bronchioles
10. Give medication
as ordered to
alleviate
respiratory
distress such as
salbutamol
CUES NURSING OUTCOME RATIONALE RATIONALE EVALUATION
DIAGNOSIS
Subjective: Impaired gas At the end of 2 1.) Assess 1. To know what
exchange n/t days nursing causative/contribu when where and
Objective: accumulation of interventions, ting factors how to manage
>cyanosis noted secretions on pt will be able 2.) Note respiratory the condition
>diaphoresis air passage to: rate, depth, use of appropriately
>Inability to secondary cap accessory muscles
move secretion Demonstrate 3.) Auscultate breath 2. To know
>pallor improved sounds when to give
>Slow capillary ventilation by 4.) Elevate head of prompt
repill:2 sec. stop using bed intervention
>Use of supportive 5.) Review pertinent because degree
accessory laboratory data of ventilation
muscle when Verbalize 6.) Change position
breathing under-standing frequently 3. Presence of
>Fatigue of causative 7.) Encourage deep abnormal
>On inhalation factors and breathing exercise breath sounds
@1L/min via appropriate 8.) Provide secondary in the lungs
nasal cannula interventions inhalation as indicate degree
>Pursed-lip Participate in indicated like 02 or area of
breathing treatment inhalation sputum
regimen 9.) Encourage production
adequate rest and
limit activities 4. Promotes
within pt’s lung expansion
tolerance a proper
ventilation

5. These are
reliable sources
of data that
gives reliable
result
6. Promotes
secretion of
sputum /
phlegm

7. Facilitates
breathing
8. supportive
management
used to help
the body
compensate
with the 02
demand of the
body
9. additional
activities will
contribute to
respiratory
compromised
CUES NURSING OUTCOME INTERVONTIONS RATIONALE EVALUATION
DIAGNOSIS
Subjective: Ineffective At the end of 3 1. Identify 1. To identify
airway clearance days causative/ the precipitating
r/t increase intervention pt precipitating factors of the
Objective: production of will be able to: factors condition of pt
bronchial 2. Position the to know the
>loud crackling secretion Maintain airway head of pt appropriate
sounds heard secondary to potency above the action related
when coughed pneumonia bed’s head the pt’s
Readily 3. Suction condition
>DOB noted expectorate/ naso/tracheal 2. Promotes
 Clear secretions / oral PRN to proper lung
>(+) crackles on clear airway expansion
both lungs upon Verbalize 4. Encourage 3. To clear
auscultation understanding of deep airway
the causes and breathing and 4. Promotes
>RR:36cpm therapeutic coughing expectoration
regimen exercises 5. Improves
>Dyspnea noted 5. Administer cough effort
analgesics 6. Help loosen
>Cyanosis 6. Increase fluid phlegm for easy
observed on the in take expectoration
lips and fingers 7. Provide 7. Helps dilate
supplemental airway, thus
>Restlessness humidification promotes
such as breathing
>Fatigue nebulizer 8. Monitor
8. Aucultate respiratory rate
>Diaphoresis breath sounds and note any
and assess changes that
>Use of respiratory need prompt
accessory movement intervention
muscles for 9. Monitor V/S, 9. Sings of
breathing noting blood/ system
pulse changes complication
10. give brought by
salbutamol as ineffective
ordered airway clearance
will be notes
10. helps dilate
bronchioles