ASSESSMENT NURSING GOAL INTERVENTION RATIONALE IMPLEMENTATION(CONTROL EVALUATION

DIAGNOSIS (PRESCRIPTIVE OPERATION) (REGULATORY

(DIAGNOSTIC OPERATION) OPERATIONS)
OPERATION)
• Auscultate This assessment Breath sound She felt
Subjective breath sounds determines the auscultated.Patient having comfortable as
q2-4h, and presence of crackles on left side. her cough
date The patient adventitious
report decreased as
Patient Ineffective demonstrates breath sounds
changes Semi fowlers position evidenced by
verbalized airway effective
• Assist the As the patient’s
given.patient felt decreses
that “I have clearance cough. patient into a comfortable crackles on
condition
severe cough related to Following position of worsens, auscultation
with yellow copious trachea intervention, comfort, sputum can Sputum color is
sputum bronchial the usually semi- become more yellowish.sputum culture
Fowler’s copious and sent for culture and
secretions as patient’s
position. change in color sensitivity
Objective evidenced by airway is free
• Inspect
Data coughing with of adventitious sputum for This position Oxygen administered
On productive breath sounds provides through nasal cannula.2 lit
quantity,
comfort and /minit.patient felt
assessment cough odor, color, facilitates ease
patient is and comfortable
and
expectorating consistency; effectiveness
yellowish • Deliver Salbutamol nebulisation
oxygen with This given BD.patient verbalized
sputum. humidity as that her cough decreasing
intervention
prescribed. provides
• Administer oxygenation Psychological support given
bronchodialato while
rs decreasing
convective

1
 losses of
moisture and
helping
mobilize
secretions.