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    Assessment Diagnosis Planning Implementation Rationale Evaluation

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    Mica Omotsosirc
    1) The patient reports difficulty breathing due to coughing and retained secretions. Objective findings include restlessness, adventitious lung sounds, and increased respiratory rate. 2) The plan is for the nurse to implement interventions within 2 hours to clear secretions and improve breathing patterns through positioning, pursed lip breathing, coughing techniques, and suctioning as needed. 3) After 2 hours of nursing interventions, the patient's status will be reassessed and is expected to have clearer airways and improved breathing.

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    Assessment Diagnosis Planning Implementation Rationale Evaluation

    Uploaded by

    Mica Omotsosirc
    29 views5 pages
    1) The patient reports difficulty breathing due to coughing and retained secretions. Objective findings include restlessness, adventitious lung sounds, and increased respiratory rate. 2) The plan is for the nurse to implement interventions within 2 hours to clear secretions and improve breathing patterns through positioning, pursed lip breathing, coughing techniques, and suctioning as needed. 3) After 2 hours of nursing interventions, the patient's status will be reassessed and is expected to have clearer airways and improved breathing.

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    1) The patient reports difficulty breathing due to coughing and retained secretions. Objective findings include restlessness, adventitious lung sounds, and increased respiratory rate. 2) The plan is for the nurse to implement interventions within 2 hours to clear secretions and improve breathing patterns through positioning, pursed lip breathing, coughing techniques, and suctioning as needed. 3) After 2 hours of nursing interventions, the patient's status will be reassessed and is expected to have clearer airways and improved breathing.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    29 views5 pages

    Assessment Diagnosis Planning Implementation Rationale Evaluation

    Uploaded by

    Mica Omotsosirc
    1) The patient reports difficulty breathing due to coughing and retained secretions. Objective findings include restlessness, adventitious lung sounds, and increased respiratory rate. 2) The plan is for the nurse to implement interventions within 2 hours to clear secretions and improve breathing patterns through positioning, pursed lip breathing, coughing techniques, and suctioning as needed. 3) After 2 hours of nursing interventions, the patient's status will be reassessed and is expected to have clearer airways and improved breathing.

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    Assessment Diagnosis Planning Implementation Rationale Evaluation

    Subjective: Patient Ineffective Within 2 hours of Independent: After 2 hours of


    reports difficulty in breathing pattern nursing nursing
    breathing related to retained intervention the  Position the  To maintain intervention the
    secretion patient will be able patient in semi- airway patient cleared
    Objective to clear from fowlers from secretions
     Use of secretions and position and improved
    accessory improve breathing breathing pattern
    muscles pattern  Pursed lip
     Shortness  Demonstrate breathing
    of breath pursed lip helps slow
     Productive breathing expiration,
    cough prevents
     Wheezing collapse of
    V/S small
    RR: 25bpm airways.
    CR: 127bpm
     Demonstrate  Helps to
    effective promote
    coughing and optimal
    deep-breathing chest
    techniques expansion
    and
    drainage of
    secretions

     Instruct patient  For


    to increase mobilization
    water intake of
    secretions
    but avoid
    fluid
    overload

    Dependent:  Suctioning
    clear
     Suction secretions
    secretions as that obstruct
    needed the airway
    therefore
    improves
    oxygenation

     Provide  Aid in
    respiratory relieving the
    support. patient from
    Oxygen dyspnea.
    inhalation is
    given as
    ordered.
     More
     Administer aggressive
    bronchodilators measures to
    if prescribed maintain
    airway
    patency
    Assessment Diagnosis Planning Implementation Rationale Evaluation
    Subjective: Ineffective After 3 hours of nursing Independent: After 3 hours of nursing
    “Minsan hinahabol Airway intervention the client will intervention the client will
    ko yung hininga ko clearance be able to:  Monitor  To indicative be able to:
    dahil sa pag- ubo related to respiration and of respiratory
    ko.” As the retained breath sound distress
    verbalized by the mucus  Maintain airway and/or  Maintain airway
    patient. secretion as clearance/patenc accumulation clearance/patency
    evidenced y of secretion
    Objective: by  Maintain proper
     Restlessnes unproductiv  Maintain proper  Encourage  To loosen fluid volume
    s e cough. fluid volume hydration at secretion
     DOB least 8 glasses  Clear secration
     Adventitious of water a day readily
    sound  Clear secration
    (crackles) readily  Encourage  To limit
    Vs: adequate rest fatigue
     RR of 27 period
    bmp
     Position head  To open or
    appropriate for maintain
    condition such open airway
    as fowler’s in at rest or
    position compromised
    individual

    Dependent;

     Administer  Aid relieving


    supplemental the patient
    oxygen as from
    ordered. dsypnea

     Administer
    medication as  More
    prescribed by aggressive
    the physician . measures to
    maintain
    airway
    patency

    Assessment Diagnosis Planning Implementation Rationale Evaluation

    Subjective: Impaired gas After 2 hours of  Establish  To build After 2 hours. of


    “ Nahihhirapan exchange related to nursing intervention, rapport. trusting nursing intervention
    akong huminga alveolar capillary the patient will relationship. the client shall return
    paminsan-minsan” membrane verbalize demonstrate
    As the verbalized by destruction. understanding of breathing
    the patient. causative factors  Monitor and  To have techniques.
    and appropriate record V/S. baseline
    Objective: intervention. data.

     (+) DOB  Maintain  Monitor skin  Duskiness


     (+) chest patent and mucous and central
    pain (pain airway. membrane cyanosis
    scale 8/10) color indicate
     (+) Body advanced
    weakness hypoxemia
     (+)
    Wheezing  Position the  To maintain
    upon patient.in airway.
    auscultation semi fowler’s
    position.

    Vital Signs:
    RR: 27cpm  Maintain
    (tachypnea) adequate  Encourage  Promote
    Input and frequent optimal chest
    PR: 102 bpm Output. position expansion
    (tachycardia) changes and and drainage
    deep of secretions
    breathing/
    coughing
    exercise

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