63%(8)63% menganggap dokumen ini bermanfaat (8 suara)
8K tayangan2 halaman
NUNEZ, Marie Jesedel G. Patient's name: A.L. ASSESSMENT Objective: Appears weak and restless with changes in rate, rhythm and depth of breathing Appears tachypnic with moderate to large secretions in the mouth.
NUNEZ, Marie Jesedel G. Patient's name: A.L. ASSESSMENT Objective: Appears weak and restless with changes in rate, rhythm and depth of breathing Appears tachypnic with moderate to large secretions in the mouth.
Hak Cipta:
Attribution Non-Commercial (BY-NC)
Format Tersedia
Unduh sebagai DOC, PDF, TXT atau baca online dari Scribd
NUNEZ, Marie Jesedel G. Patient's name: A.L. ASSESSMENT Objective: Appears weak and restless with changes in rate, rhythm and depth of breathing Appears tachypnic with moderate to large secretions in the mouth.
Hak Cipta:
Attribution Non-Commercial (BY-NC)
Format Tersedia
Unduh sebagai DOC, PDF, TXT atau baca online dari Scribd
ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTIONS RATIONALE EVALUATION OBJECTIVE: Ineffective Airway The inflammation After 2hours of 1. Monitor V/S - To have a baseline After the 2hours of Clearance related to and increased nursing interventions especially data. nursing interventions - Appears weak & Retained Secretions secretions make it the patient will respiratory rate the goal was met restless in the mouth difficult to maintain demonstrate 2. Auscultate - To ascertain status because the patient a patent airway, behaviors to improve breath sounds, and note progress established - With changes in which airway patency. note areas of or complications effective airway rate, rhythm and is cause by decrease decreased/ clearance and depth of ability to expel the adventitious effective respirations breathing excessive mucus breath sounds as as evidenced by produced that will well as fremitus absence of secretion - Appears lead to extensive 3. change - To maximize in the mouth. tachypnic obstruction of the position respiratory effort airway. every 2 hours as and mobilize - With moderate to necessary secrections large secretions in (Medical-Surgical - To maintain or the mouth. Nursing; 4. suction clear the airway. Brunner & secretion that are - Vital Signs taken: Suddarth”s) retained in the - To promote TEMP: 36.4 mouth. wellness BP: 120/70 5. Encourage RR:12 adequate rest and PR: 90 limit activities to within client - To treat tolerance underlying 6. Administer conditions and medications such mobilize as secretions bronchodilators/ expectorants as indicated NUÑEZ, Marie Jesedel G. ICU BSN 4B
Patient’s name: A.L. ICU Room no. 3
ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTIONS RATIONALE EVALUATION Objective: Risk for Skin Decreased muscle After 2hrs of 1. Assess skin - this may indicate After 2 hours of Integrity r/t physical strength nursing routinely, noting particular nursing intervention - physical immobility ↓ intervention, the moisture, color, vulnerability the goal was met immobility Body weakness client will be and elasticity. - that may further because we were - neuromascular ↓ able to demonstrate 2. Note presence of impair skin able to demonstrate impairment Irritability behaviors/technique Conditions/ integrity the proper ↓ s to prevent skin Situations. interventions to Physical immobility breakdown with the 3. Observe for other - Reduces prevent skin ↓ help of the bedside reddened/blanched likelihood breakdown during Risk for skin nurse. areas or skin of progression to the 8hour shift. integrity rashes, skin and institute breakdown (Medical-Surgical treatment Nursing; immediately Brunner & 4. Provide adequate - To prevent Suddarth”s) clothing/covers vasoconstriction. and postioning every 2hours. 5. Emphasize - To maintain importance of general good adequate health and skin nutritional/fluid turgor intake