DULNUAN, PRESLEE K.

3B- GROUP 6A
Assessment Nursing Planning Intervention Rationale Evaluation
Diagnosis
Subjective: Ineffective Short Term: Independent: 1. Generate good Short Term:
“ breathing was airway After 4 hours of 1. Build or establish rapport and connection, trust and Goal met,
challenging, and I clearance nursing collaboration. participation with the following a 4-hour
felt as if I were related to intervention the patient. nursing
being suffocated, increased patient will 2. Monitor respiratory rate, intervention, the
with my chest sputum demonstrate depth, and breath sounds at 2. Basic indicators of patient managed
tightening” as production as improve least every 4 hours. respiratory effort. to improve
verbalized by the evidenced by behaviors to behaviors
patient. abnormal achieve airway 3. Maintain appropriate 3. Basic safety precautions. to achieve airway
breath sounds, clearance. emergency equipment as clearance.
tachypnea, dictated by the situation.
Objective: and purulent Long Term: Long Term:
 Wheezing and sputum. After 2 days of 4. Assist the patient into a 4. Provides comfort and Goal met, after
crackles upon nursing position of comfort, usually promotes better lung two days of
auscultation intervention the semi-Fowler’s position. expansion. nursing
 Shallow, rapid patient will intervention the
maintain a 5. Help the client deep breath 5. Controlled coughing patient
breathing
patent airway and perform controlled uses the diaphragmatic maintained a
 Thick and
with clear breath coughing. Have the client muscles, making the patent airway
tenacious
sounds, inhale deeply, hold breath for cough more forceful and with clear breath
secretions
expectorate several seconds, and cough effective. sounds,
RR- 28 bpm
BP- 130/80 mmHg clear secretions, two or three times with mouth expectorated
Temp- 37.4 and improve open while tightening the clear secretions,
oxygen upper abdominal muscles. and had
exchange. 6. Helps mobilize improved oxygen
6. Encourage activity and exchange.
ambulation as tolerated. If the secretions and reduces
client cannot be ambulated, atelectasis.
turn the client from side to
side at least every 2 hours. 7. Fluids help minimize
mucosal
7. Maintain adequate hydration
by forcing fluids to at least
3000 mL/day unless
contraindicated. Offer warm,
rather than cold, fluids.
8. Teach the client/family the
importance of taking
antibiotics as prescribed,
consuming all tablets until the
prescription has run out
Collaborative
9. Anticipate the need for
supplemental oxygen or
intubation if the patient’s
condition deteriorates.
10. If indicated, encourage the
client to use an incentive
spirometer.
11. Administer medications
(bronchodilators or inhaled
steroids) as ordered. Watch
for side effects.
12. Assist with bronchoscopy and
thoracentesis, if indicated.
drying and maximize
ciliary action to move
secretions.
8. Taking the entire course
of antibiotics helps
eradicate bacterial
infection, which
decreases lingering,
chronic infection.
9. These measures are
needed to correct the
hypoxemia.
10. Recognize that
controlled coughing and
deep breathing may be
just as effective as
incentive spirometry
11. Bronchodilators
decrease airway
resistance, improve the
efficiency of
respiratory movements.
12. Occasionally needed to
remove mucous plugs