ASSESSMENT

NURSING
DIAGNOSIS
INFERENCE GOAL
NURSING
INTERVENTION
RATIONALE EVALUATION

Subjective:
"nahihirapan ako
huminga as
verbalized by the
patient.

Objective:
- Use of
accesso
ry
muscles
during
inhalatio
n and
expiratio
n
- Chest
tube
intact
and
draining
to dark
red
exudate
s

O neffective
airway
clearance
r/t lung
impairment

rritant


nflammatory
response



ncrease
production of
secretions



Airways
constriction


dyspnea

O After 30
minutes of
nursing
interventio
n, patient
airway is
achieved
and there
is
improvem
ent in the
airway
clearance

O Pain was
assessed,
encouraged
deep
breathing
and
coughing
exercises


O Amount,
viscosity,
color and
odor of
sputum
were
monitored

Dependent
O Administ
er
humidific
ation
and
nebulize
r
theraphy
as
prescrib
ed

O Helps to
achieve
maximal
lung
inflation
and to
open
closed
airways

O Changes
in sputum
may
suggests
presence
of
infection


O Secretion
s must be
moistened
and
thinned if
they are
to be
raised
from the
chest with
the least

O After
30
minut
es of
nursin
g
interv
ention
. The
goal
is met
throug
h the
patien
t
verbal
izing
that
he is
free of
acute
distre
ss
and
feels
much
more
comfo
rtable.



ndependent

O Location
,
characte
r and
severity
of pain
was
evaluate
d.



O Maintain
ed care
in
positioni
ng the
patient.
Placed
in a
semil
Fowler's
position
and
turning
or the
patient
amount of
effort


O Pain limits
chest
excursion
and
decreases
ventilation



O The
patient
who is in
semi-
fowlers
permits
residual
air in the
plural
space to
rise to
upper
portion of
pleural
space and
be
removed



ASSESSMENT
NURSING
DIAGNOSIS

INFERENCE
GOAL
NURSING
INTERVENTION

RATIONALE

EVALUATION

Subjective
"medyo
kumikirot ung
dibdib ko as
verbalized of the
patient.

Objective:

O Facial
grimace

O P/S of
7/10

O Acute
paint r/t
drainage,
incision

Trauma



Release of
arachidonic
acid



ncrease
prostaglandin



pain

After 30
minutes of
nursing
intervention,
pain intensity
as verbalized
will be lessen
from 7/10 to
4/10

O Location,
character,
quality and
severity of
pain was
evaluated

O Px position in
semi-fowler







O ncision of
drainage was
assessed for
redness and
drainage
O Encourage for
deep
breathing
exercise

O Pain limits
chest
excursion
and
thereby
decreases
ventilation
O Semi
fowler
helps the
patient in
expanding
and less
pain will
be felt by
the patient
O Signs of
indication
for
infection
O t
promotes
patient for
unlabored
breathing

After 30
minutes of
nursing
intervention
the patient will
verbalize
signs of free
from distress
and
comfortable.
There is no
sign of
incisional
infection.