Student Name: Tremaine Codner

Class: Oxygen

Patients Diagnosis: Pleural effusion, Emphysema, lung ca?

ASSESMENT NURSING NURSING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS OUTCOME

Subjective Ineffective At the end of 8 1. Position patient in 1.To maintain Goal partially met.
airway clearance hours of nursing semi fowlers patent airway. An At the end of 8
Patient verbalize related to retain and position upright position hours of nursing
“Mi a try cough up secretion as collaborative allows for maximal and collaborative
the cold, but it evidence by care patient will 2. Give patient 1.5 L air exchange and care patient was
difficult fi me” patient demonstrate of liquid to drink lung expansion. able to drink 1L of
verbalizing effective airway fluids (tea and
Objective difficulty to clear clearance AEB 3. Teach client deep 2. Fluids ensure water), expelled
secretion from productive breathing and optimal hydration approximately 2cc
Adventitious respiratory tract, coughing and controlled coughing. and loosening of of hemoptysis
breath sound adventitious clear breath secretions. sputum and
(crackles) breath sounds, sounds. Client 4. Monitor maintain a Spo2 of
hemoptysis ( will also respiratory pattern 3. To clear airway 95%.
hemoptysis ( 5cc) in sputum maintain vitals and vital signs. and facilitate o2
5cc) in sputum bowl, diminished within normal delivery to lung.
bowl breath sound, range Spo2 (95- 5. Reassess patients
decrease tactile 100%) and R:12- ability to cough 4. secretions in the
diminished breath fremitus and 20 bpm and effectively to clear airway, causes an
sound hypo- resonance, drink adequate secretion increase in
Spo2- 93-94%, R- amount of fluids respiratory rate.
decrease tactile 21 bpm. (1.5 L).
fremitus 5. To observe
patient’s ability to
hypo- resonance. clear secretion
from the airway
Spo2: 93%-94% effectively.

R-21 bpm
 Student Name: Tremaine Codner

Need: Rest Comfort and Activity

Patients Diagnosis: Lung cancer

ASSESMENT NURSING NURSING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS OUTCOME

Subjective Decrease activity At the end of 8 1. Establish a 1.This allows the Goal partially met.
tolerance related hours of nursing therapeutic patient to voice At the end of 8
Patient verbalize to imbalance and collaborative relationship with complaint/concerns hours of nursing
“Lord help me, between o2 care patient will patient. freely. and collaborative
mi cah tek this supply and demonstrate an care patient was
nuh more, mi cah demand improvement in 2. Provide 2. To reduce energy able to maintain a
move too fast secondary to activity tolerance assistance with expenditure. spo2 of 94-95%, p-
because of the lung cancer as as evidence to activity and 97-101 bpm, R-20-
SOB. Mi have evidence by perform activities ambulation as 3. To have a 21 bpm. Patient
cancer inna mi shortness of freely without SOB necessary. baseline data to verbalized feeling
chest” breath, and maintain vital check for better when he sat
generalized signs within normal 3. Monitor vital sign improvement and upright in bed with
Patient weakness, power range (BP, Pulse, to prevent exertion the support of the
verbalized feeling grade rate 2/5, (Spo2: 95%-100%), respiration and during activities. bed side table.
better when he spo2- 91-92% on R 12-20 bpm, p: spo2) during and
sat upright in bed 4 L of humidified 60-100 after activity. 4. To provide
with the support O2, R-21 bpm, P- bpm) enough rest period
of the bed side 115 bpm 4. Cluster patient for the client.
table. care.

Objective

Exertional
discomfort

Generalized
weakness

Power grade rate

2/5

Spo2- 91-92% on
4 L of humidified
o2

R-21 bpm

P-115 bpm