ASSESSMENT

Subjective cues:
"Nagla-lock yung
panga niya nung
dinala namin dito,
tapos di niya
mailabas yung
plema nya", as
verbalized by
patient's watcher
Objective cues:
-with
tracheostomy tube
hooked to
mechanical
ventilator on AC
mode, FiO2 95%,
Tidal Volume 420,
BUR 36
-copious, blood
tinged, viscous
secretions per
trachea
-moderate,
yellowish, thin
secretions per
orem
-crackles on
bilateral lung fields
-active muscular
spasms
-dyspneic; nasal
flaring

NURSING
DIAGNOSIS
Ineffective
airway
clearance
related to the
accumulation of
sputum in the
mouth and
trachea and
respiratory
muscle spasm

PLANNING
Long term goal:
After 48 hours of
nursing
intervention, the
patient will be
able to manifest
effective airway
as indicated by:
RR: 16-20 bpm
No nostril
breathing
Normal ABG
result

Short term goal:

After 2 hours of
nursing
intervention, the
patient will have
airway cleared
from secretions.

INTERVENTION
Independent:
1. Assess patient's
health condition.
Obtain vital signs.

2. Place patient in
moderate high back
rest position.

3. Auscultate breath
sounds.

4. Suction secretions
per orem and
tracheosotmy tube
with
hyperventilation pre
and post suctioning.
5. Regulate
intravenous fluids.

RATIONALE
Dyspnea, cyanosis is a
sign of breathing
disorder which is
accompanied by
decreased cardiac
work arising
tachycardic refill time
and capillary length /
time.
The anatomy of the
head position of the
extension is a way to
align the respiratory
cavity so that the
process of respiration
is still running
smoothly by removing
the blockage of the
airway.
Ronchi shows an upper
respiratory problem
due to fluid or
respiratory secretions
that covered most of
the respiratory tract
that need to be
removed to optimize
the airway.
When you suction, you

EVALUATION
Goal met.
After 48 hours of
nursing
intervention, the
patient was able
to manifest
effective airway
as indicated by:
RR: 20 bpm
No nostril
breathing
Normal ABG
result

Goal met.
After 2 hours of
nursing
intervention, the
patient have
airway cleared
from secretions.

-ABG: Respiratory
Acidosis,
Uncompensated
Vital signs:
CR: 147 cpm
BP: 130/80 mmHg
Temperature:
39.2C
RR: 49 bpm
O2 Saturation:
89%

6. Watch out for the

onset of respiratory
failure / apnea.

provide assistance in
clearing the airway of
secretions and then
simplify the process of
respiration.
Measures to thin
tenacious secretions
and reduce drying of
the respiratory
mucous membrane.

Dependent:
1. Oxygenate
according to
doctors orders.

2. Administer
secretion-thinning
medication
(mucolytics) as
ordered.

3. Render
nebulization of
bronchodilators or
saline solution as
ordered.

The inability of the

body in the respiratory
process requires
immediate and critical
interventions by using
a breathing support
(mechanical
ventilation).

The provision of
adequate oxygen can
supply and provide
backup oxygen, thus
preventing hypoxia.
These drugs can thin
the thick secretions
making it easy to
remove and prevent
viscosity.

Measures to thin
tenacious secretions
and reduce drying of
the respiratory
mucous membrane.

ASSESSMENT
Subjective cues:
"Kailan po siya
pwede kumain sa
bibig? ang laki na
po kasi ng pinayat
niya," as patient's
watcher
verbalized.
Objective cues:
-with Nasogastric
tube fr 16 on left
nostril patent and

NURSING
DIAGNOSIS
Altered
nutrition, less
than body
requirements
related to the
mastication
muscle stiffness

PLANNING

INTERVENTION

Long term goal:

After 1 week of
nursing
interventions, the
client will be able
to maintain
desired body
weight.

Independent:
1. Assess for and
report signs and
symptoms of
malnutrition:
weight below client's
usual weight or
below normal for
client's age, height,
and body frame
abnormal BUN and
low serum albumin,
Hct, Hb, blood

RATIONALE
Obtain baseline data
for reference and to
check patient's
readiness to eat per
orem.

EVALUATION
Goal met.
After 1 week of
nursing
interventions, the
client was able to
have desired
body weight.

Goal met.

intact
-on osteorized
feeding of 1500
kcal/ day divided
by 6 equal
feedings at 250ml
every 4 hours
-with occasional
spasms
- low serum
Albumin
-HGT: 89mg/dL
-weak and pale
Vital signs:
CR: 89 cpm
BP: 130/80 mmHg
Temperature:
37.1C
RR: 25 bpm
O2 Saturation:
97%

Short term goal:

After 2 hours of
nursing
intervention, the
patient will be
able to tolerate
food and fluid per
Nasogastric tube.

glucose and
lymphocyte levels
weakness and
fatigue
sore, inflamed oral
mucous membrane
pale conjunctiva,
gag reflex.
2. Obtain a dietary
consult if necessary
to assist client in
selecting
foods/fluids that
meet nutritional
needs, are
appealing, and
adhere to personal
and cultural
preferences.

To maintain an
adequate nutritional
status

To minimize fatigue

Encourage food intake

3. Encourage a rest
period before meals.
4. Maintain a clean
environment and
relaxed, pleasant
atmosphere.
5. Provide oral
hygiene before
meals (removes
unpleasant tastes,
which often
improves the taste

Promote normal
routine

Prevent
gastrointestinal
distention ) in order to
prevent feeling of
fullness and early
satiety

After 2 hours of
nursing
intervention, the
patient was able
to tolerate food
and fluid per
Nasogastric tube.

of foods/fluids).
6. Serve frequent,
small meals rather
than large ones if
client is weak,
fatigues easily,
and/or has a poor
appetite.
7. Encourage
significant others to
be present to assist
client with meals if
needed.

To make eating more

of a familiar social
experience

Support patient's
nutritional needs

Support patient's
nutritional needs

8. Administer
osteorized feedings
with strict aspiration
precaution.
Dependent:
1. Consult physician
about an alternative
method of providing
nutrition (e.g.
parenteral nutrition,
Albumin) if client
does not tolerate
enough food or
fluids to meet
nutritional needs.
2. Administer
vitamins and

Support patient's
nutritional needs

minerals as ordered.