ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS EXPLANATION

SUBJECTIVE: INEFFECTIVE Tracheobronchial LONG TERM INDEPENDENT: LONG TERM

BREATHING obstruction OUTCOME: OUTCOME
Stated: PATTERN Assess Respiratory ACHIEVED:
“Nahihirapan RELATED TO  After 2 days of respiratory rate and rate and rhythm
akog huminga at TRACHEO- nursing depth by listening to changes are After 2 days of
saka kinakapos Amounts of fluid are intervention, the lung sounds. early warning nursing
BRONCHIAL
ako sa drained from the client will be able signs of intervention, the
OBSTRUCTIO
paghinga.” pleural cavity to: impending client will be able
N
SECONDARY respiratory to:
 Establish a Note muscles
TO PLEURAL difficulties.
normal/effective used for Establish a
OBJECTIVE: EFFUSION AS fluid pressure in breathing(sterno-
respiratory these signify normal/effective
EVIDENCED the pleural cavity cleidomastoid,
pattern AEB an increase in respiratory pattern
Dyspnea BY DYSPNEA diaphragmatic) and
 absence of s/s of work of breathing AEB absence of
hypoxia, normal retractions/flaring of s/s of hypoxia,
Observed
Atelectasis in the skin color. nostrils normal skin color.
physical
discomfort affected side of the
position client
lung
with proper body
use of SHORT TERM This is for good SHORT TERM
 alignment(semi-
accessory OUTCOME: lung excursion OUTCOME
fowler’s position)
muscle noted and chest ACHIEVED:
Impaired cardiac
After 4 hours of expansion
oxygen in use filling/inflamed
nursing After 4 hours of
via nasal pleural membranes
intervention, the Ensure that nursing
cannula, 2- client will be able oxygen delivery intervention, the
(intensified on
3L/min inspiration) to: system is applied to this provides client will be able
the patient, the adequate to:
mucus/secreti  verbalize appropriate amount oxygenation to
on awareness of of oxygen is prevent patient verbalize
Dyspnea, difficulty in causative factors awareness of
delivered from desaturation
production breathing, altered causative factors
chest excursion, demonstrate pace and
respiratory depth appropriate schedule activities demonstrate
changes coping behaviors providing adequate appropriate
like proper rest periods coping behaviors
breathing and This prevents like proper
dyspnea resulting breathing and
Reference: Medical coughing Encourage
from fatigue
Surgical sustained deep coughing
Nursing:Brunner 11th breaths by
these promote
edition, p.652 emphasizing slow
deep inspiration
inhalation, holding
end inspiration)

Teach client
appropriate deep
breathing and
coughing
techniques these facilitate
adequate
clearance of
secretions
COLLABORATIVE:

Administer
oxygen at lowest For
concentration management of
indicated underlying
pulmonary
condition and
respiratory
 distress.

Refer the client to --.for proper

a dietician and or counseling and
support groups. intake of caloric
needs.