Assessment Nursing Scientific Goals and Objectives Nursing Intervention Rationale Evaluation

Diagnosis Explanation
Subjective Ineffective In high cervical spine SHORT TERM INDEPENDENT SHORT TERM
“Hirap siya breathing injuries, spinal cord After 8 hours of nursing After 8 hours of nursing
huminga ng pattern innervation to the phrenic intervention the patient/SO  Encourage patient to fluids (at Aids liquefying secretions, intervention, the goal was partially
mabuti lalo na related to nerve w/c stimulates the will promoting mobilization and met, as evidenced by:
least 2000ml/day).
diaphragm is lost.
kapag merong impairment expectoration.  The patient was able to
(Brunner, 2010 p. 1936)
tuluyang of  Maintain adequate maintain adequate ventilation as
pagpulikat” as innervation ventilation as evidence evidence by absence of
With injuries to the
verbalized by the of diaphragm cervical and upper by absence of  Assist with coughing as respiratory distress, ABG within
significant others thoracic spinal cord, respiratory distress, indicated for level of injury; Adds volume to cough and normal limits, and pulse
innervation to the major ABG within normal e.g have client take deep facilitates expectoration of oximetry maintained at 90% or
accessory muscles of limits, and pulse breath for 2 sec. before secretions or help move them greater
Objective respiratory is lost and oximetry maintained at coughing, or inhale deeply high enough to be suctioned
respiratory problems 90% or greater then cough at the end of a slow out.  The patient was able to
 Vital Signs develop. These include  Demonstrate appropriate exhalation. Alternatively assist demonstrate appropriate
RR- 28 decrease vital capacity, behaviors to support by placing hands below behaviors to support respiratory
HR- 123 retention of secretions,
respiratory effort such as diaphragm and pushing effort such as focused deep
increase PaCo2, decrease
O2 saturation – focused deep breathing upward as client exhales. breathing during muscle spasms
oxygen levels, respiratory
93% failure and pulmonary during muscle spasms and establish a normal or
edema. and establish a normal effective respiratory pattern
 Minimal nasal or effective respiratory with ABGs on acceptable range.
flaring is noted pattern with ABGs on  Assist client in taking control
 Reduced voice acceptable range. of respirations as indicated. Breathing may no longer be a  The patient was not able to
and tactile Instruct and encourage deep totally involuntary activity but demonstrate appropriate coping
 Exhibits  Demonstrate appropriate breathing focusing attention on require conscious effort, behaviors
labored and coping behaviors steps of breathing. depending on level of
using of injury/involvement of  The significant other was able
accessory  Verbalize awareness of respiratory muscles. to verbalize awareness of
muscles causative factors causative factors
 Breath sounds-  Reposition/turn periodically. Enhances ventilation of all lung
crackles on  Initiate lifestyle changes Avoid/limit prone position segments, mobilizes secretions,  The patient was not able to
both lungs with the help of the SO when indicated. reducing risk of infection. Note: initiate lifestyle changes with
prone position significantly the help of the SO
Diagnostic test decreases vital capacity, and
 Chest X-ray increase risk of resp.
shows compromise failure.
interstitial
 pneumonitis,
both lungs  Note client’s level of injury Injuries at C5 can result in
 ABGs shows when assessing respiratory variable loss of respiratory
partially function. Note presence or function, depending on the
compensated absence of spontaneous effort phrenic nerve involvement and
respiratory and quality of respiration. (e.g. diaphragmatic function but
alkalosis, with labored, using accessory generally cause decreased vital
adequate muscles) capacity and inspiratory effort.
oxygenation (Doenges, NCP p.274)
 MRI of
cervical spine
shows that  Maintain client airway: keep
there is spinal head in neutral position, Clients with high cervical injury
cord elevate head of bed slightly if and impaired cough reflex
compression at tolerated, and use airway needs assistance in preventing
C3 to C4 level adjunct as indicated. aspiration/maintaining patent
airway.

Preventing retained secretions is

 Assist with use of respiratory essential to maximize gas
adjuncts: incentive spirometer diffusion

 Maintain a calm attitude,

assisting client to “take Assist client to deal with the
control” by using physiologic effects of hypoxia
slower/deeper respirations. which may be manifested as
anxiety and fear.

DEPENDENT

 Administer oxygen by
appropriate method as Method determine by level of
prescribed by the physician injury, degree of respiratory
(Nasal cannula) insufficiency.
COLLABORATIVE

Check serial ABGs. Document status of ventilation

and oxygenation, identifies
respiratory problems