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    Assessment Diagnosis Planning Intervention Rationale Evaluation

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    Nica Pineda
    The patient was having difficulty breathing without oxygen. An assessment found increased respiratory rate, wheezing, productive cough, and inability to clear secretions. The diagnosis was ineffective airway clearance due to excess secretions. Short term goals were to maintain or improve airway patency through monitoring, hydration, positioning, rest, and clearing secretions. Long term goals were for the patient to demonstrate behaviors to maintain a clear airway. Nursing interventions like oxygen, bronchodilators, and secretion removal were aimed at improving respiratory status over 3 days.

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    Assessment Diagnosis Planning Intervention Rationale Evaluation

    Uploaded by

    Nica Pineda
    40 views2 pages
    The patient was having difficulty breathing without oxygen. An assessment found increased respiratory rate, wheezing, productive cough, and inability to clear secretions. The diagnosis was ineffective airway clearance due to excess secretions. Short term goals were to maintain or improve airway patency through monitoring, hydration, positioning, rest, and clearing secretions. Long term goals were for the patient to demonstrate behaviors to maintain a clear airway. Nursing interventions like oxygen, bronchodilators, and secretion removal were aimed at improving respiratory status over 3 days.

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    NCP

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    Ncp

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    The patient was having difficulty breathing without oxygen. An assessment found increased respiratory rate, wheezing, productive cough, and inability to clear secretions. The diagnosis was ineffective airway clearance due to excess secretions. Short term goals were to maintain or improve airway patency through monitoring, hydration, positioning, rest, and clearing secretions. Long term goals were for the patient to demonstrate behaviors to maintain a clear airway. Nursing interventions like oxygen, bronchodilators, and secretion removal were aimed at improving respiratory status over 3 days.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    40 views2 pages

    Assessment Diagnosis Planning Intervention Rationale Evaluation

    Uploaded by

    Nica Pineda
    The patient was having difficulty breathing without oxygen. An assessment found increased respiratory rate, wheezing, productive cough, and inability to clear secretions. The diagnosis was ineffective airway clearance due to excess secretions. Short term goals were to maintain or improve airway patency through monitoring, hydration, positioning, rest, and clearing secretions. Long term goals were for the patient to demonstrate behaviors to maintain a clear airway. Nursing interventions like oxygen, bronchodilators, and secretion removal were aimed at improving respiratory status over 3 days.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    Assessment Diagnosis Planning Intervention Rationale Evaluation

    Subjective: Ineffective airway Short term: Independent Short term:


    clearance related to
    “nahihirapan siyang After 8 hours of nursing - Monitor respiration and - To indicate if there is After 8 hours of nursing
    presence of secretion
    huminga kapag walang intervention, the patient will breath sounds. intervention, the patient
    respiratory distress
    oxygen.” as verbalized be able to: and/or further was able to
    by the patients wife accumulation of maintain/improve airway
    Inference : -Maintain or improve airway clearance patency.
    clearance or patency. secretion.
    Inhales microorganisms - Maintain adequate - To loosen secretion
    Objective: Long term: hydration
    Transmitted to alveoli Long term:
    -RR: 23 CPM After 3 days of nursing - Elevated head of the bed
    Less function intervention the patient will - To open or maintain After 3 days of nursing
    in fowlers position.
    - Difficulty of breathing (impaired gas be able to: open airway in at rest. intervention the patient
    exchange) was able to demonstrate
    - Wheezing upon -Demonstrate behaviors to
    auscultation - Encourage adequate rest behaviors to improve/
    Mucus production improve or maintain clear - To limit fatigue
    periods. maintain clear airway
    -Productive cough airway.
    Phagocyte produce
    -Inability to expectorate Collaborative
    phlegm Accumulation of
    exudates in alveoli - Assist with procedures - To maintain clear and
    -with oxygen therapy such as administering open airway.
    Mucus secretion Oxygen.

    Ineffective airway - Administer - To promote


    clearance bronchodilator pharmacologic
    medications as regimen.
    prescribed.

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