ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Ineffective airway During the client’s stay After nursing

clearance related to at the hospital he will ♦ Assessed respiratory ♦ Provides a basis for intervention the client
S>“Nahihirapan sya increased production of be able to maintain was able to display
bronchial secretions patent airway as rate. evaluating adequacy patency of airway as
huminga dahil sa
plema.” as verbalized evidenced by: of ventilation. manifested by:
by the client’s wife.  Successful T-piece
 Independence from
♦ Use of accessory weaning by
oxygen and ♦ Noted chest
O>On endotracheal muscles of achieving the goal of
tube attached to a ventilatory support movement; use of
respiration may completing 60mins.
mechanical ventilator accessory muscles
with increasing occur in response to
duration of T-piece during respiration.
weaning (5, 15, 30, 45, ineffective
60 mins.) ventilation.
♦ Auscultated breath
sounds; noted areas ♦ Crackles indicate
with presence of accumulation of
adventitious sounds. secretions and
♦ Documented inability to clear
respiratory airways.
secretions: character
♦ Expectorations
and amount of
sputum.
♦ Maintained patient
on moderate high
back rest.
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Risk for aspiration After 8 hours of -asses patient for -to determine After 8 hours of
related to presence of nursing intervention the presence of aspiration nursing intervention
S> N/A nasgo gastric tube patient will experience client experienced no
no aspiration as -while feeding put the -to prevent aspiration aspiration as evidenced
evidence by noiseless patient in semi-fowlers by noiseless respiration,
respiration clear breath position clear breath sounds and
sounds and absence absence of cyanosis
cyanosis -be aware of misplaced -to prevent aspiration
of the tube while feeding

-auscultate lungsound -to monitor if tere is

frequently aspiration happening

-after feeding maintain

patient in semi-fowlers
O>N/A position for 30 mins
before putting to
comfort position
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Risk for infection After8 hours of nursing -ssess and monitor -to monitor After 8 hours of
related to presence of intervention patient will patient frequently thecondition of the nursing intervention the
S> N/A naso gastric tube be free of patient patient was free of
microorganisms that -wash hands before -to prevent microorganism that
causes infection doing insertion, feeding microorganism from causes infection
or lavage entering the patient.

-use sterile materials in To prevent

inserting NGT feeding microorganism from
nad lavage entering the patient

-replace NGT avery 72 -to prevent growth of

hours microorganisms

O>N/A -maintain the -to prevent growth of

cleanliness of the room microorganism

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

 Difficulty of breathing After 5 mins of nursing - position patient in - maximum lung After 5mins of nursing
related to presence of intervention patient will semi-fowlers position expansion intervention the patient
S> “Nahihirapan akong naso gastric tube improve respiration as improve his respiration
huminga” as verbalized manifested by -assess if the -to determine if the ngt as manifested by
by the patient NGT is well place is obstructing the normal RR.
airway
-provide O2 therapy
PRN -to improve
oxygenation
-suction mucus - to removee secretion
secretion that obstruct and cleae airway
the airway PRN

-assess and monitor the -to check if the patients

breathing patern of the breathing pattern is
patient frequently improving
O>dyspnea noted
>facial grimace
>RR-23 cpm