Assessment Nursing Planning Intervention Rationale Evaluation

Diagno
Long Term Short Term Selected Implemented
sis

Subjective:
Ineffective During the Following an ♦ Assess ♦ Assessed ♦ Provides a At the end of
“Nahihirapan airway client’s stay 8-hr nursing respiratory respiratory basis for the shift, the
sya huminga
clearance at the intervention, function, rate. evaluating client was
dahil sa
related to hospital he the client will e.g., adequacy able to
plema.” as
increased will be able to be able to: breath of display
verbalized by
production of maintain  Achieve sounds, ventilation patency of
the client’s
bronchial patent airway successful rate, and ♦ Noted . airway as
wife.
secretions as evidenced progressiv use of chest manifested
secondary to by: e T-piece accessory movement ♦ Use of by:
Objective:
fluid shift to  Independe weaning of muscles ; use of accessory  Successful
 On
extravascular nce from (5-15-30- and accessory muscles of T-piece
endotrach
compartment oxygen 45-60 secretion muscles respiration weaning
eal tube
. and mins) characteri during may occur by
attached
ventilatory stics and respiration in achieving
to a
support  Sustain amount. the goal of
. response
mechanica respiratory completing
to
l ventilator  Normal rate within 60mins.
ineffective
with respiration normal
♦ Auscultate ventilation
increasing as range: RR-  Client’s
d breath .
duration of evidenced 12-20 respiratory
sounds;
T-piece by cpm. rate is
noted ♦ Crackles
weaning
Assessment Nursing Planning Intervention Rationale Evaluation
Diagno
Long Term Short Term Selected Implemented
sis

(5, 15, 30, absence of areas with indicate

within
45, 60 dyspnea presence accumulati
normal
mins.) and of on of
range: RR-
adventitio adventitio secretions
18 bpm.
 Abnormal us breath us sounds. and
breath sounds inability to  Secretions
sounds: (wet  Display ♦ Document clear decreased
wet crackles). decreasing ed airways. in amount
crackles amount of respiratory from 40 cc
on (R) and  Normal secretions secretions: ♦ Expectorat to 30 cc
(L) lung breathing (less than character ions may collected
bases. pattern: 40cc). and be in an 8-hr
RR = 12-
amount of different shift
 Dyspnea; 20 cpm  Allay
♦ Position sputum. when (Continue
use of restless-
patient in secretions assessmen
accessory  Absence of ness.
semi- or ♦ Maintained are very t of
muscles bronchial
high- patient on thick. respiratory
for secretions
Fowler’s moderate status and
respiration
 Normal position. high back suctioning
: elevated
chest x- rest. ♦ Positioning as
shoulders.
ray results ♦ Assess helps needed).
 Increase in airway maximize
Assessment Nursing Planning Intervention Rationale Evaluation
Diagno
Long Term Short Term Selected Implemented
sis

respiratory  Allay patency. lung

rate: RR- restless- expansion.
25 cpm ness

 Secretion
♦ Suction as ♦ To
characteri ♦ Checked
needed maintain
stics: for
when adequate
yellowish obstructio
patient is airway  Client’s
in color ns:
experienci patency. restlessne
and 40 ml accumulati
ng ss was
in amount on of
difficulty ♦ Duration alleviated
collected secretions.
of should be and
in an 8-hr
breathing, limited to remained
shift. ♦ Suctioned
limiting reduce calm.
patient
 Chest x- duration of hazard of
limited to
ray suction to hypoxia,
5-sec
reports 15 sec or damage
duration.
haziness less. airway

on both mucosa

lower ♦ Administer and impair

hemithora medicatio cilia

x taken on ns as action.
Assessment Nursing Planning Intervention Rationale Evaluation
Diagno
Long Term Short Term Selected Implemented
sis

Septembe
r 7, 2006.
♦ Increases
 Restless
lumen size
of the
tracheobro
indicated: nchial
Bronchodil tree, thus
ators. decreasing
resistance
to airflow
and
improving
oxygen
delivery.

Subjective:
Anticipatory During the Following an ♦ Encourage ♦ Explained ♦ Active At the end of
“Malungkot grieving patient’s stay 8-hr nursing active every participati the shift, the
siya.” As related to at the management, participati procedure on client was
verbalized by loss of hospital, he the client will on of done to maintains able to:
the client’s physiological will be able to be able to: patient in the patient patient  Have an
Assessment Nursing Planning Intervention Rationale Evaluation
Diagno
Long Term Short Term Selected Implemented
sis

wife. well-being appropriately  Develop care and and independe improved

secondary to progress awareness treatment family. nce and awareness
Objective:
progressive through which decisions. control. as
 With debilitating grieving leads to ♦ Approache manifested
episodes disease. process as therapeuti ♦ Nurse d the ♦ Frequent by
of evidenced c crying. should family and contact therapeuti
occasional by: visit the establishe helps c crying
crying  Client  Cooperate family d rapport reduce (continue
grieving with frequently with the feelings of providing
 Sadness treatment
process and patient’s isolation emotional
progressin procedure provide family. and support).
 Loss of
g from s. physical abandonm
appetite
 Participate
phase 2 contact as ent.
 Remain d in
 Fatigue (feeling) to appropriat ♦ Sat with
calm. treatment
phase 3 e. patient
 General procedure
(dealing)  Improve and family ♦ This allows
discomfort s.
as sleeping ♦ Allow quietly for
theorized pattern periods of and used emotional
 Uncoopera  Remained
by (uninterru crying and active expression
tive with calm: allay
Rodebaug pted sleep expression listening .
procedure restlessne
h et. al. of at least of as
s. ss.
sadness. therapeuti
Assessment Nursing Planning Intervention Rationale Evaluation
Diagno
Long Term Short Term Selected Implemented
sis

 Restless  Developin c
g communic
 Mostly flat awareness ation.
affect which
leads to ♦ Encourage ♦ Patient
 Changes
therapeuti ♦ Encourage d patient may feel
in sleeping
c crying. verbalizati and family supported
pattern:
on of to express in  Sleeping
interrupte  Cooperate thoughts/c their expression pattern
d sleep with oncerns thoughts of feelings improved:
every hour treatment
2 hours). and accept and by the slept for 2
at night procedure expression concerns understan hours
and fully s. s of by asking ding that (night
awake
sadness, open- deep and shift).
during  Remain
anger, ended often
daytime. calm.
rejection. questions conflicting

 Loss of  Uninterrup (e.g. “Tell emotions

independe ted sleep me how are normal

nce: at least 6 you’re and

functional hours. coping.”). experience

level IV. d by
 Patient, others in
Assessment Nursing Planning Intervention Rationale Evaluation
Diagno
Long Term Short Term Selected Implemented
sis

♦ Arrange
care to
provide for
uninterrup
ted
periods for
rest, for this
with his
especially difficult
family, will
allowing situation.
seek social ♦ Maintained
for longer
support a relaxed,
periods of ♦ To assist
and calm, non-
sleep at client to
resources stimulatin
night establish
appropriat g
when optimal
ely. environme
possible. sleep/rest
nt.
Do as pattern.
much care
as possible
without
waking the
client.
Assessment Nursing Planning Intervention Rationale Evaluation
Diagno
Long Term Short Term Selected Implemented
sis