Assessment Subjective:

Diagnosis

Planning

Intervention

Rationale

Evaluation After 2 days of nursing intervention, the patient displayed time healing of pressure sores.

Impaired skin Within 2 Assessed tissues, For comparative integrity days of bony prominences, baseline data naaawa na ko and pressure areas related to nursing sa kapatid ko, physical intervention, Assessed adequacy To assess degree of ang dami na nya immobilizatio the patient of blood supply and impairment kasi bed sores innervations of the n as will display eh as tissue on the sole manifested by timely facilitate verbalized by part of the right foot To the presence healing of healing. Promoted optimum the patients of pressure pressure nutrition with highbrother sores sores quality protein and without sufficient calories, complicatio vitamins, and ns Objective: mineral Inference Disruption of skin surface/ presence of wound on lower back Redness around wounds Physical immobilizatio n VS: -abyss wala ako copy ng vs at gcs niya Tsaka pla palagay nalang kung gano na sya katagal sa hosp. Di ko alam eh, sorry physical immobilizatio n

GOAL WAS MET

friction on lower back (sacral part)

supplements promote Strictly follow the To circulation and implementation and prevent excessive posting of a turning tissue pressure schedule, restricting 2 hours or less and time in one position to customizing the schedule to patients routine. Practiced aseptic To reduce the risk for crosstechnique for contamination cleansing/dressing/ medicating lesions To see changes Monitored indicative of laboratory values. healing/infection/ complications.

redness on skin

disruption of skin surface

Tissue damage/eru ption of skin

Assessment

Diagnosis Ineffective airway clearance related to retained secretions

Planning Within 2 days of nursing intervention, the patient will demonstrate absence/ reduction of congestion with breath sounds clear, respiration noiseless, improve oxygen exchange

Intervention

Rationale

Evaluation Within 2 days of nursing intervention, the patient demonstrated absence/ reduction of congestion with breath sounds clear, respiration noiseless, improved oxygen exchange as

Subjective:

ang daming secretions na lumalabas sa bibig at tracheostomy ng kapatid ko., as Inference verbalized by physical the patients immobilizatio brother.
n

Assess patients To gain the trust and cooperation condition Monitor and record V/S Auscultate lung To know and fields, noting areas determine patients needs. To identify of decreased/absent areas of airflow and consolidation and adventitious breath determine possible sounds bronchospasm or obstruction. Assist patient to To mobilize change position secretions every 30 minutes Elevate head of bed To facilitate and align head in breathing the middle

Objectives:

Crackles, upon auscultatio inability to n, on both expel lungs secretions Ineffective / absent cough extensive Excessive obstruction sputum airway RR O2 satineffective airway clearance

retained secretions

manifested by:

RR: remove Suction every 2 To O2 sat: obstructed mucus hours or as necessary Administer meds as To reduce ordered. bronchospasm and mobilize secretion Nebulisation of combivent every 8 hours

1. Ineffective Airway Clearance NDx: Ineffective airway clearance related to presence of secretions secondary to pneumonia. The inflammation and increased secretions make it difficult to maintain a patent airway, which is cause by decrease ability to expel the excessive mucus produced that will lead to extensive obstruction of the airway.

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