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    Assessment Planning Intervention Rationale Evaluation: Nursing Diagnosis

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    Lovely Cacapit
    The document outlines a nursing care plan for a patient experiencing difficulty breathing due to copious mucopurulent secretions. Over 1-2 weeks of nursing intervention, the patient will be able to effectively expectorate secretions, maintain oxygenation, and be comfortable with ambulation and complying with their health regimen. Interventions include monitoring respiratory status, suctioning secretions, administering bronchodilators if prescribed, teaching breathing exercises, and chest physiotherapy.

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    Assessment Planning Intervention Rationale Evaluation: Nursing Diagnosis

    Uploaded by

    Lovely Cacapit
    41 views2 pages
    The document outlines a nursing care plan for a patient experiencing difficulty breathing due to copious mucopurulent secretions. Over 1-2 weeks of nursing intervention, the patient will be able to effectively expectorate secretions, maintain oxygenation, and be comfortable with ambulation and complying with their health regimen. Interventions include monitoring respiratory status, suctioning secretions, administering bronchodilators if prescribed, teaching breathing exercises, and chest physiotherapy.

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    nursing care plan

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    The document outlines a nursing care plan for a patient experiencing difficulty breathing due to copious mucopurulent secretions. Over 1-2 weeks of nursing intervention, the patient will be able to effectively expectorate secretions, maintain oxygenation, and be comfortable with ambulation and complying with their health regimen. Interventions include monitoring respiratory status, suctioning secretions, administering bronchodilators if prescribed, teaching breathing exercises, and chest physiotherapy.

    Copyright:

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

    Assessment Planning Intervention Rationale Evaluation: Nursing Diagnosis

    Uploaded by

    Lovely Cacapit
    The document outlines a nursing care plan for a patient experiencing difficulty breathing due to copious mucopurulent secretions. Over 1-2 weeks of nursing intervention, the patient will be able to effectively expectorate secretions, maintain oxygenation, and be comfortable with ambulation and complying with their health regimen. Interventions include monitoring respiratory status, suctioning secretions, administering bronchodilators if prescribed, teaching breathing exercises, and chest physiotherapy.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION

    SUBJECTIVE: After 1 week of nursing Monitor respiratory rate, depth, Increased respiratory rate, use
    After 1 week of nursing intervention
    intervention the patient will: and effort, use of accessory of accessory muscles, nasal
    the patient
    “nahihirapan ako huminga muscles, nasal flaring, and flaring, and abdominal breathing
    kapag nakahiga ako” Maintain a patent airway at all abnormal breathing patterns may indicate hypoxia.
    Maintained a patent airway at all times
    times
    OBJECTIVE: Auscultate breath sounds. Note Presence of crackles, wheezes
    adventitious breath sounds. may signify airway obstruction,
    After 2-3 days of nursing intervention
    -persistent productive cough After 2-3 days of nursing leading to or exacerbating
    the patient
    -difficulty of breathing intervention the patient will: existing hypoxia
    -restlessness
    Demonstrates effective expectoration
    -presence of wheezes upon Effectively expectorate Monitor and graph serial ABG’s, Establishing a baseline for
    of secretions
    auscultation secretions pulse oximetry, chest x-ray monitoring progression or
    -Cyanosis regression of disease process
    Patients was able to manifest signs of
    Patient will be able to manifest complications.
    good oxygenation
    signs of good oxygenation
    Place patient in an orthopnic To maintain an open airway
    Patient has shown compliance to the
    Patient will be comfortable in position when appropriate
    health regimen
    NURSING DIAGNOSIS: terms of ambulation and comply
    with health regimen Assist to turn every 2 hours. If Movement aids in mobilizing
    Ineffective Airway Clearance ambulatory, allow patient to secretions to facilitate clearing
    related to copious mucopurulent ambulate as tolerated or airways
    secretions as evidenced by
    presence of productive cough Demonstrate effective coughing Helps maximize ventilations
    and deep-breathing techniques

    Encourage abdominal or Provides patients with some


    pursed-lip breathing exercises means to cope with or control
    dyspnea and reduce air-trapping

    Demonstrate chest These techniques will prevent


    physiotherapy, such as possible aspirations and prevent
    bronchial tapping when in any untoward complications.
    cough, proper postural drainage
    DEPENDENT:

    Suction secretions as ordered Suctioning clear secretions that


    obstruct the airway therefore
    improves oxygenations

    Administer bronchodilators if More aggressive measures to


    prescribed maintain airway patency

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