ASSESSMENT

Objective:
- RR: 29
- (+) bibasilar
crackles
both lung
fields
- Cyanosis on
extremities
- Shortness of
breath

NURSING
DIAGNOSIS
Ineffective
Airway
Clearance due
to Pulmonary
edema

SCIENTIFIC
ANALYSIS
The inflammation
and increased
secretions make it
difficult to
maintain a patent
airway, which is
cause by decrease
ability to expel
the excessive
mucus produced
that will lead to
extensive
obstruction of the
airway.

GOALS /
INTERVENTIONS
OBJECTIVES
After long term
Position the patient upright
nursing intervention,
if tolerated. Regularly
the patient will be
check the patients
able to:
position to prevent sliding
down in bed
Establish
airway
patency
Auscultate breath sounds
Expectorate
q 1hr
fluid
accumulated
in the lungs

RATIONALE

Have clear
breath sound
Demonstrate
increased air
Monitor respiratory
exchange.
patterns, including rate,
depth, and effort.
Classify
methods to
enhance
secretion
removal.
Help client to deep breathe
and perform controlled
coughing. Have client

Upright position limits

abdominal contents from
pushing upward and
inhibiting lung expansion.
This position promotes
better lung expansion and
improved air exchange.
Breath sounds are
normally clear or scattered
fine crackles at bases,
which clear with deep
breathing. The presence of
coarse crackles during late
inspiration indicates fluid
in the airway; wheezing
indicates an airway
obstruction.

A normal respiratory rate

for an adult without
dyspnea is 12 to 16. With
secretions in the airway,
the respiratory rate will
increase.

This technique can help

increase sputum clearance

EVALUATION
After long term nursing
intervention, the patient
was able to:
1. Maintained airway
patency
2. Excrete fluid in the
lungs
3. Have clear breath
sound
4. Demonstrated
increase in air
exchange.
5. Classified methods
to enhance
secretion removal.

inhale deeply, hold breath

for several seconds, and
cough two to three times
with mouth open while
tightening the upper
abdominal muscles.

and decrease cough

spasms (Celli, 1998).
Controlled coughing uses
the diaphragmatic
muscles, making the
cough more forceful and
effective.

Encourage client to use

incentive spirometer.

Observe sputum, noting

color, odor, and volume.

The incentive spirometer

is an effective tool that can
help prevent atelectasis
and retention of bronchial
secretions

Normal sputum is clear or

gray and minimal;
abnormal sputum is green,
yellow, or bloody;
malodorous; and often
copious.

Fluids help minimize

mucosal drying and
maximize ciliary action to
move secretions (Carroll,
1994). Some clients
cannot tolerate increased
fluids because of
underlying disease.

Oxygen has been shown to

correct hypoxemia, which

Encourage increased fluid

intake of up to 3000
ml/day within cardiac or
renal reserve.

Administer oxygen as
ordered.

can be caused by retained

respiratory secretions.
Administer medications
such as bronchodilators or
inhaled steroids as
ordered. Watch for side
effects such as tachycardia
or anxiety with
bronchodilators, inflamed
pharynx with inhaled
steroids.
Provide postural drainage,
percussion, and vibration
as ordered.

Bronchodilators decrease
airway resistance
secondary to
bronchoconstriction.

Chest physiotherapy helps

mobilize bronchial
secretions; it should be
used only when prescribed
because it can cause harm
if client has underlying
conditions such as cardiac
disease or increased
intracranial pressure

Assessment
Objective:
- RR: 29
- BP 75/40
mmHg.
- HR 130s
- (+)
bibasilar
crackles
both lung
fields
- Cyanosis
on
extremitie
s
- Shortness
of breath

Nursing
Diagnosis
Risk for falls
related to
decrease in
blood pressure

Scientific
Analysis
Hypotension or
low blood
pressure causes
dizziness when
standing which
can increase the
risk for falls.

Objectives
After long term
nursing intervention,
the patient will be
able to:
Verbalize
understandin
g of
individual
risk factors
that
contribute to
the
possibility of
falls
Demonstrate
behaviors and
lifestyle
changes to
reduce risk
factors and
protect self
from injury
Modify
environment
as indicated
to enhance
safety
Be free of
injury

Interventions

Rationale

Consider hazards in the

care setting

Identifying needs or
deficits provides
opportunities for
intervention and/ or
instruction

Assist in treatments and

provide information
regarding clients
disease/condition

To reduce or correct
individual risk factors

Increase fluid intake if

not contraindicated

Recommend or
implement needed
interventions and safety
devices

Fluids increase blood

volume and help prevent
dehydration, both of
which are important in
treating hypotension.

Place bed in lowest

possible position, use a
raided- edge mattress,
pad floor at side of bed,
or place mattress on the
floor as appropriate
Use half side rail instead
of full side rails or
upright pole

To manage conditions that

could contribute to falling
and to promote safe
environment for
individual
To ensure safety of the
client

To assist individual in
arising from bed

Evaluation
After long term nursing
intervention, the patient
was able to:
Verbalize
understanding of
individual risk
factors that
contribute to the
possibility of
falls
Demonstrate
behaviors and
lifestyle changes
to reduce risk
factors and
protect self from
injury
Modify
environment as
indicated to
enhance safety
Be free of injury

Assessment
Objective:
- RR: 29
- BP 75/40
mmHg.
- HR 130s
- (+)
bibasilar
crackles
both lung
fields
- Cyanosis
on
extremitie
s
- Shortness
of breath

Nursing
Diagnosis
Decreased
cardiac output
related to
reduction in
stroke volume

Scientific
Analysis
Preload is the
degree of
myocardial fiber
stretch before
contraction. It is
related to the
volume of blood
distending the
ventricles at the
end of diastole.
It is determined
by the amount of
venous return.
Since there is an
alteration in the
venous return,
the preload is
affected.
Alteration in the
preload affects
the stroke
volume and
resulting to
decrease cardiac
output.

Objectives
After long term
nursing intervention,
the patient will be
able to:
Display
hemodynami
c stability
Report/
demonstrate
decreased
episodes of
dyspnea
Demonstrate
an increase
in activity
tolerance
Participate in
activities that
reduce the
workload of
the heart

Interventions

Rationale

Keep Client on bed or

chair rest in position
of comfort

Decreases oxygen
consumption and risk of
decompensation

Administer high-flow
oxygen via mask or
ventilator, as ordered

To increase oxygen
available for cardiac
function/ tissue perfusion

Monitor vital signs

frequently

To note response to
activities and
interventions

Monitor urine output

hourly

Administer analgesics,
as appropriate

Evelate legs when in a

sitting position; apply
sequential
compression devices,
if indicated

A drop in urine output

may indicate decreased
renal perfusion as a result
of decreased stroke
volume secondary to
cardiac compression.
To promote comfort/rest
to be able to promote
venous return
To enhance venous return

To reduce anxiety and

Evaluation
After long term nursing
intervention, the patient
was able to:
Display
hemodynamic
stability
Report/
demonstrate
decreased
episodes of
dyspnea
Demonstrate an
increase in
activity
tolerance
Participate in
activities that
reduce the
workload of the
heart

ASSESSMENT

NURSING

SCIENTIFIC

GOALS /

Encourage relaxation
techniques

INTERVENTIONS

conserve energy

RATIONALE

EVALUATION

Objective:
- Patient is
stretcherborne
- Thin
- Cyanosis on
extremities

DIAGNOSIS
Risk for
Impaired Skin
Integrity

ANALYSIS
Skin is the primar
y defense of the
body; it protects
the body
againstinfections
and dsesbrought a
bout by theinvasi
on of microbes in
the body. A
normal skin is
moist and intact;
dryness of the
skin is more
prone to friction
that may result to
impairment of the
skin
integrity as comp
ared with a moist
skin

OBJECTIVES
After an hour of
Inspect skin for
nursing
skeletal prominences,
interventions, the
presence of edema,
patient will be able
areas of altered
to:
circulation, and/or
emanciation
Maintain
skin integrity Encourage frequent
position changes,
Demonstrate
assist with active and
behaviors to
passive range of
prevent skin
motion (ROM)
breakdown
exercises.

No visible
redness
present

Skin is at risk because of

impaired peripheral
circulation, physical
immobility, and alterations
in nutritional status.

Reduces pressure on
tissues, improving
circulation and reducing
time any one area is
deprived of full blood
flow.

Provide gentle massage

around reddened or
Improves blood flow,
blanched areas.
minimizing tissue hypoxia.
Encourage an egg-crate
Reduces pressure to skin,
like mattress
may improve circulation.
Avoid intramuscular
route for medication.

Interstitial edema and

impaired circulation
impede drug absorption
and predispose to tissue
breakdown
and development of
infection.

After an hour of nursing

interventions, the patient was
able to:

Maintain skin integrity

Demonstrated
behaviors to prevent
skin breakdown

Showed no signs of
redness and irritation
on skin