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Assessment Nursing diagnosis Scientific Planning Intervention Scientific rationale Evaluation

April 26, 2010 Discharge outcome: independent: February 24, 2010
2:00PM inhales 12:00pm
Ineffective airway microorganism After 1 week of  Monitor respiration  To indicative of
Subjective: clearance related to nursing intervention and breath sound respiratory Discharge outcome:
retained mucus transmitted to alveoli the client will be able distress and/or
Stated: secretion as to: accumulation of Partially achieve
evidenced by  Demonstrate secretion
“nahihirapan akong unproductive cough less behaviors to After 1 weeks of
huminga” as function(impaired improve or  Encourage  To loosen nursing intervention
verbalized by the gas exchange) maintain clear hydration at least secretion the client can be able
patient airway such as 8 glasses of to:
mucus production following water/day
(inflammatory pharmacologic  Demonstrate
Objectives: reaction) regimen and  Position head  To open or behaviors to
doing pursed lip appropriate for maintain open improve or
Phagocyte produce technique condition such as airway in at rest or maintain clear
 Inability to  Demonstrate fowler’s position compromised airway such as
expectorate Accumulation of absence of individual following
phlegm exudates in alveoli mucus secretion pharmacologic
with breath  Encourage  To limit fatigue regimen and
 Behavioral ⬆ mucus secretion sounds clear adequate rest doing pursed lip
changes: respiratory period technique
restlessness ineffective airway noiseless Collaborative
Short term out come:  Assist with  To maintain clear Short term outcome:
 Adventitious procedure such as open airway
sound After 2 days of administering O2
Reference: medical nursing intervention Achieve
surgical nursing: 11th the client will be able  Administer  To promote
 DOB edition volume 1 to: medication such pharmacologic After 2 days of
Brunner and  Maintain airway as bronco dilators regimen nursing intervention
Suddarath clearance/patenc the client can be able
 RR of 27 bpm y to:
 Maintain proper  Assist with  A various
fluid volume monitor therapies may
 Clear secretion hypothermia acquire/maintain  Maintain airway
readily therapy use of adequate airways clearance/patency
respiratory device improve  Maintain proper
and treatment respiratory fluid volume
function and gas  Clear secretion
exchange readily