ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Ineffective airway During the client’s stay At the end of the
“Naglisod siya clearance related to at the hospital he will shift, the client was
pagghinhawa.”as increased be able to maintain able to display
verbalized by the production of patent airway as patency of airway
client’s wife. bronchial secretions evidenced by: Provides a basis for evaluating adequacy of as manifested by:
Objective: secondary to fluid Assessed respiratory rate. ventilation. .
On endotracheal shift to Client’s respiratory
tube attached to a extravascular >Independence from Use of accessory muscles of respiration may rate is within
mechanical compartment. oxygen and ventilatory occur in response to ineffective ventilation. normal range: RR-
ventilator Abnormal support Noted chest movement; use of accessory 18 bpm.
breath sounds: wet >Normal respiration as muscles during respiration. Crackles indicate accumulation of secretions and Secretions
crackles on (R) and evidenced by absence inability to clear airways. decreased in
(L) lung bases. of dyspnea and amount from 40 cc
Dyspnea; use of adventitious breath Auscultated breath sounds; noted areas with Expectorations may be different when secretions to 30 cc collected in
accessory muscles sounds (wet crackles). presence of adventitious sounds. are very thick. an 8-hr shift
for respiration: >Normal breathing (Continue
elevated shoulders. pattern: RR = 12-20 Documented respiratory secretions: character assessment of
Increase in cpm and amount of sputum. respiratory status
respiratory rate: >Absence of bronchial and suctioning as
RR-25 cpm secretions Maintained patient on moderate high back Positioning helps maximize lung expansion. needed).
Secretion >Sustain respiratory rest. Client’s restlessness
characteristics: rate within normal was alleviated and
yellowish in color range: RR-12-20 cpm. To maintain adequate airway patency. remained calm.
and 40 ml in >Display decreasing Checked for obstructions: accumulation of
amount collected in amount of secretions secretions. Duration should be limited to reduce hazard of
an 8-hr shift. (less than 40cc). hypoxia, damage airway mucosa and impair cilia
Chest x-ray reports Suctioned patient limited to 5-sec duration. action.
haziness on both
lower hemithorax
taken on September Increases lumen size of the tracheobronchial tree,
7, 2006. thus decreasing resistance to airflow and
Restless improving oxygen delivery.