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NUÑEZ, Marie Jesedel G.

ICU BSN 4B

Patient’s name: A.L. ICU Room no. 3


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

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