Assesment Diagnosis Planning Intervention Rationale Evaluation

Suazo, Trisha Mae S.
10/6/20
3BSN-A
ASSESMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Ineffective airway After 8 hours of 1.Monitor respiratory Provides a basis for After the end of shift:
“I find it difficult to clearance related nursing intervention rate, breath sounds, chest evaluating adequacy of -patient’s respiratory
breath and I have to patient will: movement, use of ventilation. rate is within normal
cough for days and it tracheobronchial -maintain patent accessory muscle while range (18bpm)
won’t stop. I also secretions as airway breathing -secretions are decreased
sweat at night and my evidenced by -expectorate - Patient’s weight is
weight is now 59 kg abnormal breath secretions 2. Note ability to Expectoration may be slowly going back to
from 67 kg. ” As sounds and -demonstrate expectorate mucus and difficult when secretions normal
verbalized by Mr. dyspnea. behaviors to cough effectively; are very thick as a result -patient verbalizes
Howe. improve/maintain document character, of infection and/or understanding of disease
airway clearance. amount of sputum, inadequate hydration. process/prognosis and
Objective: presence of hemoptysis. Blood-tinged or frankly prevention.
-dyspnea Imbalanced -Demonstrate bloody sputum results -patient verbalizes
-abnormal breath nutrition: less than progressive weight from tissue breakdown understanding of
sounds: crackles body requirements gain toward goal (cavitation) in the lungs or therapeutic regimen and
-weight loss related to frequent with normalization from bronchial ulceration rationale for actions.
-productive cough cough production, of laboratory values and may require further
-restlessness dyspnea as and be free of signs evaluation or intervention.
evidenced by of malnutrition.
VS taken as ff: weight loss of 1o% -Initiate 3. Place patient in semi
T: 37.8 from normal behaviors/lifestyle or high-Fowler’s Positioning helps
P: 76 BPM weight. changes to regain position. Assist patient maximize lung expansion
RR: 24 bpm and/or to maintain with coughing and deep- and decreases respiratory
BP: 110/70 appropriate weight. breathing exercises. effort. Maximal
ventilation may open
Deficient -Verbalize atelectatic areas and
knowledge of understanding of promote movement of
preventive health disease secretions into larger
measures and process/prognosis airways for expectoration.
treatment regimen and prevention. 4. Clear secretions from
-Initiate mouth and trachea; Prevents obstruction and
behaviors/lifestyle suction as necessary. aspiration. Suctioning
changes to improve may be necessary if
general well-being 5. Maintain fluid intake patient is unable to
-Verbalize of at least 2500 mL/day expectorate secretions.
understanding of unless contraindicated. High fluid intake helps
therapeutic regimen 6. Humidify inspired air thin secretions, making
and rationale for and oxygen them easier to expectorate.
actions.
Prevents drying of
7. Administer mucous membranes and
medications as indicated: helps thin secretions.
Mucolytic agents:
acetylcysteine Reduces the thickness and
(Mucomyst) stickiness of pulmonary
secretions to facilitate
8. Ascertain patient’s clearance.
usual dietary pattern.
Include in selection of
food. Helpful in identifying
specific needs and
strengths. Consideration
of individual preferences
9 Monitor I&O and may improve dietary
weight periodically. intake.
Useful in measuring
10. Encourage and effectiveness of nutritional
provide for frequent rest and fluid support.
periods.
Helps conserve energy,
especially when metabolic
11. Provide oral care requirements are increased
before and after by fever.
respiratory treatments.
Reduces bad taste left
from sputum or
medications used for
respiratory treatments that
12. Encourage small, can stimulate the vomiting
frequent meals with center.
foods high in protein and
carbohydrates. Maximizes nutrient intake
without undue
fatigue/energy
expenditure from eating
large meals, and reduces
13. Encourage patient gastric irritation.
and SO to verbalize fears
and concerns. Answer Provides opportunity to
questions factually. Note correct misconceptions
prolonged use of denial. and alleviate anxiety.
14. Emphasize the

importance of
maintaining high-protein Meeting metabolic needs
and carbohydrate diet helps minimize fatigue
and adequate fluid intake. and promote recovery.
15. Explain medication Fluids aid in liquefying or
dosage, frequency of expectorating secretions.
administration, expected
action, and the reason for Enhances cooperation
long treatment period. with therapeutic regimen
Review potential and may prevent patient
interactions with other from discontinuing
drugs and substances medication before cure is
truly affected.
16. Review how TB is

transmitted (primarily by
inhalation of airborne
organisms, but may also Knowledge may reduce
spread through stools or risk of
urine if infection is transmission/reactivation.
present in these systems)
and hazards of
reactivation.

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Suazo, Trisha Mae S.

ASSESMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

14. Emphasize the

16. Review how TB is

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