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ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Ineffective SHORT TERM: 1. Establish Rapport 1. To gain pt’s SHORT TERM:
(none) airway After 3-4 hours 2. Monitor and trust After 3-4 hours
clearance r/t of NI, pt.’s SO record vital signs 2. To obtain of NI, pt. shall
Objective: accumulation will be able to 3. Note RR, use of baseline data have
of accessory muscles 3. To evaluate
demonstrate demonstrated
• Weak & tracheobronc & pursed lip degree of
improve airway improve airway
restless hial breathing compromise
secretions clearance as 4. Evaluate client’s clearance as
evidenced by cough/gag reflex 4. To determine evidenced by
• Irritable
reduction of and swallowing ability to reduction of
• (+)nasal congestion with ability protect own congestion with
breath sounds 5. Auscultate airway breath sounds
flaring and
clear and RR breath sounds, note 5. To ascertain clear and RR
(+) use of areas of status and note
accessory improve improve
decreased/adventiti progress or
muscles LONG TERM: ous breath sounds complications LONG TERM:
After 2-3 days of 6. Elevate head of After 2-3 days
• With DOB NI, pt. will be bed and encourage 6. To promote
of NI, pt. shall
and (+) frequent position maximal
able to establish have
wheezes changes. inspiration,
and maintain established and
enhance
airway patency. expectoration of maintained
• (+)
secretions in airway patency.
productive
order to
cough - yellow
improve
in color 7. Keep back dry ventilation
and loosen clothing 7. To promote
• warm, comfort and
flushed skin adequate
8. Instruct the SO ventilation
• (+)Tachyp to increase client’s 8. To help
nea and oral fluid intake to liquefy the
(+)Tachycardi at least 2000 secretions
a ml/day within level
of cardiac
• With tolerance.
changes in 9. Encourage deep 9. For drainage
rate, rhythm breathing exercises of secretions
and coughing
and depth of
exercises 10. Rest
breathing 10. Encourage will prevent
adequate rest and fatigue and
• With limit activities to decrease
changes in within client oxygen
rate, rhythm tolerance. demands for
and depth of metabolic
breathing demands
11. Fix bed
• Vital signs linens 11. To
promote
(RR – 54;
12. Give comfort
HR – 104; expectorants and 12. To
Temp- ; bronchodilators as further mobilize
BP- ) ordered. secretions
13. Administer
oxygen therapy and 13. To
other medications clear airway
as ordered. when secretions
are blocking the
airway indicated
to increase
14. Keep oxygen
environment saturation.
allergen-free 14. To
reduce irritant
effects on
airway

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