Assessment Nursing Diagnosis Goals & Expected Outcomes Nursing Interventions Evaluation

(Supporting data) (NANDA diagnostic statement) (Realistic, timed, measurable)
Subjective: • Pt will maintain a
Ineffective airway patent airway at all
Pt presented at ED clearance r/t times
with C/O SOB and secretions in
dypsnea bronchi and • Pt will
obstructed airway demonstrate
aeb improved ventilation
hypoxemia and and adequate
dypsnea oxygenation within
Objective: normal parameters
for her as evidenced
Pt was hypoxemic by blood gas levels
at admission; spoke before d/c
in short sentences;
used acc. muscles • Pt will maintain
when breathing clear lung fields and
remain free of signs
of respiratory
distress throughout
hospital stay
• Pt will
Demonstrate
effective coughing
techniques after
teaching session
(Strategies or actions for care) (Client’s response to nursing actions
Rationale for interventions & progress toward achieving
goals & outcomes)
 Monitor resp. rate,
depth, and effort,
use of accessory Pt’s airway remained
muscles, nasal open
flaring, and abnml
breathing patterns. Pt’s lungs remained
↑ respiratory rate, free of new onset
use of accessory wheezes
muscles, nasal
flaring, and Pt demo’d effective
abdominal breathing coughing techniques
may indicate for student nurse
hypoxia.
 Auscultate breath
sounds Q1- 2 °.
Presence of crackles,
wheezes may signify
airway obstruction,
leading to or
exacerbating
existing hypoxia.
 Observe sputum,
noting color, odor,
and volume. Normal
sputum is clear or
gray and minimal;
abnormal sputum is
green, yellow, or
bloody; malodorous;
and often copious.

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  Monitor pt’s behavior
and mental status for
onset of restlessness,
agitation, confusion,
and (in the late
stages) extreme
lethargy. Changes in
behavior and mental
status can be early
signs of impaired gas
exchange

 Monitor oxygen sats

continuously with
pulse ox. Note blood
gas results as
available. An oxygen
saturation of less
than 90% or a partial
pressure of oxygen
of less than 80 mm
Hg (normal: 80 to
100 mm Hg)
indicates significant
oxygenation
problems

 Observe for cyanosis

of the skin;
especially note color
of the tongue and
oral mucous
membranes.

 If acutely dyspneic,
consider having pt

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 lean forward over a
bedside table, if
tolerated. Leaning
forward can help
decrease dyspnea,
possibly because
gastric pressure
allows better
contraction of the
diaphragm).

 Help pt deep breathe

and perform
controlled coughing.
Have pt inhale
deeply, hold the
breath for several
seconds, and cough
two or three times
with the mouth open
while tightening the
upper abdominal
muscles as tolerated.
This technique can
help increase
sputum clearance
and decrease cough
spasms. Teach pt to
use the forced
expiratory technique,
the "huff cough."
This technique
prevents the glottis
from closing during
the cough and is
effective in clearing

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 secretions in the
central airways

 Administer
humidified oxygen
through an
appropriate device
(per the physician's
order); watch for
onset of
hypoventilation aeb
↑somnolence after
initiating or
increasing O2 tx. Pts
with chronic lung
disease may need a
hypoxic drive to
breathe and may
hypoventilate during
O2 tx

 Encourage increased
fluid intake of up to
2500 ml/day within
cardiac or renal
reserve. Fluids help
minimize mucosal
drying and maximize
ciliary action to
move secretions

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 Assessment Nursing Diagnosis Goals & Expected Outcomes Nursing Interventions Evaluation
(Supporting data) (NANDA diagnostic statement) (Realistic, timed, measurable) (Strategies or actions for care) (Client’s response to nursing actions
Rationale for interventions & progress toward achieving
goals & outcomes)
Subjective: • Pt will demonstrate  Determine the • Pt did not choke or
effective swallowing client's readiness to cough during
Impaired without choking or eat. The client needs meals
Swallowing r/t coughing during to be alert, able to
esophageal defects meals on this follow instructions, • Pt temp remained
aeb abnormality in student’s shift able to hold the head WNL during
esophageal phase erect, and able to hospital stay
Objective: by swallow study • Pt will remain free move the tongue in
from aspiration aeb the mouth. • Pt was able to
Barium esphogram clear lungs clear, demo.
found evidence of temp WNL during  Watch for appropriate
presbiesophagus hospital stay uncoordinated swallowing
and silent chewing or techniques after
penetration to • Pt will return swallowing; coughing teaching session;
vocal chords demonstrate immediately after may need
understanding of eating or delayed reinforcing before
appropriate coughing, which may d/c

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 swallowing indicate silent
techniques after aspiration; pocketing
teaching session of food; wet-
sounding voice;
sneezing when
eating; delay of more
than 1 second in
swallowing; or a
change in respiratory
patterns. If any of
these signs is
present, put on
gloves, remove all
food from the oral
cavity, stop feedings,
and consult with a
speech and language
pathologist and a
dysphagia team if
available. These are
signs of impaired
swallowing and
possible aspiration

 Avoid providing
liquids until the client
is able to swallow
effectively. Add a
thickening agent to
liquids to obtain a
soft consistency that
is similar to nectar,
honey, or pudding,
depending on the
degree of swallowing
problems. Liquids

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 can be easily
aspirated; thickened
liquids form a
cohesive bolus that
the client can
swallow with
increased efficiency

 Have suction
equipment available
during feeding.

 Watch for signs of

aspiration and
pneumonia.
Auscultate lung
sounds after feeding.
Note new crackles or
wheezing, and note
elevated
temperature. Notify
the physician as
needed. The
presence of new
crackles or
wheezing, an
elevated
temperature or white
blood cell count, and
a change in sputum
could indicate
aspiration of food . It
could also indicate
the presence of
pneumonia. Clients
with dysphagia are

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 at serious risk for
aspiration
pneumonia

 Watch for signs of

malnutrition and
dehydration. Keep a
record of food intake.
Malnutrition is
common in
dysphagic clients. A
food intake record
will allow the nurse,
speech and language
pathologist, and
dietitian to
determine the
adequacy of
nutritional intake.

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 Assessment Nursing Diagnosis Goals & Expected Outcomes Nursing Interventions Evaluation
(Supporting data) (NANDA diagnostic statement) (Realistic, timed, measurable) (Strategies or actions for care) (Client’s response to nursing actions
Rationale for interventions & progress toward achieving
goals & outcomes)
Subjective: • Pt will have no  Monitor for signs of
Infection r/t futher s/sx of infection
c/o increased chronic respiratory Pt showed no
cough, increased respiratory infection after  Administer abx as further s/sx of
sputum disease process antibiotic tx aeb ordered infection during
aeb chest wbc wnl, afebrile stay in hospital
congestion, temps, and non-  Encourage increased
increased mucopurulent fluid intake of up to
neutophil count sputum 2500 ml/day within
Objective: • Pt will verbalize cardiac or renal
reserve. Fluids help
understanding of
Wbc increased, minimize mucosal
measures to drying and maximize
neutrophils high prevent infection ciliary action to
such as adequate move secretions
nutrition, activity,
and immunizations  Increase pt’s level
of activity as
tolerated. Helps to
improve
oxygenation and
decrease secretion
retention

 Teach pt and family

s/sx of infection,
and when to report
to doctor