Date Assessment Nursing Expected Nursing Rationale Evaluation

Data Diagnosis Outcomes Interventions Criteria

08/01/2018 Pattern of Ineffective Short Term:  Determine  To identify the Short
Elimination Airway After 5-10 presence precipitating factors Term:
Clearance minutes of factors/ After 5-10
related to nursing physical minutes of
excessive intervention, conditions nursing
tenacious the client’s that would intervention,
mucus airway will cause the client’s
secretion as be cleared breathing airway was
evidenced from mucus impairments cleared from
by or secretions  Auscultate  To evaluate presence/ mucus and
ineffective will be chest character of breath the
breathing minimized & sounds/secretion secretions
pattern will establish  Evaluate  It indicates possible has been
a normal presence of obstruction minimized
respiratory secretions & will
pattern.  Elevate HOB  To promote physiological/ established a
psychological ease of normal
Decreased or maximal inspiration respiratory
absence of  Monitor  To verify pattern.
coarse pulse maintenance/improvement
crackles will oximetry in O2 saturation Decreased or
also be noted.  To clear secretions absence of
 Suction mechanically. coarse
airway every crackles was
1 hour or as also noted
upon
needed.  So that in case of transfer
auscultation.
 Enteral of fluids in the airway, it
Feeding of 8 will not further aggravate
Long Term: AM and 12 into the accumulated
After 1 week PM based on secretions & the patient Long Term:
or more, the dietician will able to breathe
patient will orders & spontaneously during After two (2)
be able to being assured feeding. days and
tolerate that the ahead, the
weaning and client’s patient was
be able to respiration is able to
breathe free or have dependently
dependently fewer with oxygen.
with oxygen. secretions
before
feeding.  To increase Fluid intake
 Add 20-30 & helps to decrease the
ml of water consistency of mucus.
before and
after the
feeding.  For baseline data
 Monitor vital
signs every
hour
especially  To manage patient if ever
RR. inconvenience or
 Refer the alteration happen.
patient and
consult with
the
Respiratory
therapist in
any alteration
in patient’s
ABG and
mechanical  To provide the baseline
ventilation. and assess patient’s
progress on her condition.
 Monitor
laboratory
results