CUES

NURSING DIAGNOIS

RATIONALE

GOALS

NURSING INTERVENTION

RATIONALE

EVALUATION

SUBJECTIVE: mukhang nahihirapan siyang huminga as verbalized by the clients wife OBJECTIVE: Nasal flaring Difficult of breathing Presence of sputum deep shallow

Ineffective Breathing Pattern related to trachea bronchialobstruction as evidenced by: SUBJECTIVE: mukhang nahihirapan siyang huminga as verbalized by the clients wife OBJECTIVE:

Tracheo bronchial obstruction

Short Term: After 1 hour of nursing intervention the client will be able to:-Establish a normal/effective respiratory pattern as

Independent: -Auscultate chest- Elevate HOB or have clients it up in chair, as appropriateStress importance of good posture and effective use of accessory muscles -Stress importance of good posture and effective use of accessory muscles - To maximize respiratory effort.for management of underlying condition or respiratory distress. -To evaluate presence / character of breath sounds/secretions

Short term: After 10 minutes of nursing intervention the goal fully met as evidence by the clients *expectorate secretions and maintain airway clearance

Amounts of fluid are drained from the pleural cavity

fluid pressure inthe pleural cavity

evidenced by absence of signs and symptoms of difficulty of

Atelectasis in the affected side of the lung

breathing with ABGs within clients normal range

*Establish a normal/effective respiratory pattern as

Impaired

breathing excessive mucus production O2 inhalation of 2Lpm Pulse oximeter= 76 percent

* Nasal flaring *difficulty of breathing * Presence of sputum |* deep shallow breathing *excessive mucus production * O2 inhalation of 2Lpm * Pulse oximeter= 76 percent

cardiac filling/inflamed pleural membranes (intensified on inspiration)

Long Term: After 2 days of nursing intervention, the client will be able to:

- Monitor respiration and breath sounds

- Indicative of respiratory distress and accumulation of secretion

evidenced by absence of signs and symptoms of difficulty of breathing. Long Term:

Dyspnea, difficulty inbreathing, Altered chest excursion, respiratory depth changes Reference: Medical Surgical Nursing: Brunner 11th edition, p.652

Establish a normal/effective respiratory pattern AEB absence of s/s of hypoxia, normal skin color.

-Encouraged deep breathing and coughing exercise

- To mobilize secretion

After 1 day of nursing intervention, the client able to: Establish a

-Increase fluid intake and food rich in Vit.C

-To moisten secretion for easy expectoration

normal/effective respiratory pattern AEB absence of s/s of hypoxia, normal

-Provide health teaching about the necessity of expectoring secretion versus swallowing them -To report changes in color amount release / decrease secretions in the

skin color.

lungs Dependent: - Administer oxygen at lower concentration indicated and prescribed respiratory medicationMonitor Pulse Oximeter as indicated COLLABORATIVE -Assist with result of necessary testing (xray) -nebulization -for easy expulsion of mucus -management to underlying condition and respiratory distress