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  • Actual - NCP. PT Agno

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    Kate Weygan
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    Actual_NCP.%20Pt%20Agno

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    4 views2 pages

    Actual - NCP. PT Agno

    Uploaded by

    Kate Weygan

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    of 2

    Assessment Diagnosis Goals Nursing Rationale Evaluation

    Interventions
    Subjective: Ineffective Breathing STG: Within 4 Dx: STG: (Goal Met)
    “Nahihirapan akong Pattern hours of Nursing 1. Monitored vital -To established -After 4 hours of
    huminga” as Interventions, signs/symptoms baseline data. Nursing Interventions,
    verbalized by the Patient the patient was able to
    patient. maintains an 2. Assessed ability -The incapability to maintain effective
    effective breathing to mobilize mobilize secretions breathing pattern
    pattern, as secretions. may contribute to a as evidenced by
    Objectives: evidenced by change in breathing relaxed breathing at
    -Received awake, relaxed breathing at patterns. normal rate and depth.
    with an ongoing IVF normal rate and 3. Observed -Unusual breathing
    of PNSS 1L×24°, depth and absence breathing patterns may imply
    1000 mL level of dyspnea. patterns. an underlying
    infusing well on the disease process or LTG: After 8 hours of
    left median vein. dysfunction. Nursing Interventions,
    -With ongoing O2 4. Assess and -It is important to the patient respiratory
    inhalation via nasal LTG: Within 8 record take action when heart rate remains
    cannula at 2 lpm. hours of Nursing respiratory rate there is an within established
    -Non-productive Interventions, and depth at alteration in limits.
    cough. Patient’s least every 2 breathing patterns
    hours. to detect early signs
    respiratory rate
    of compromise on
    remains within the respiratory
    established limits. system.
    Tx:
    1. Provide -Beta-adrenergic
    respiratory agonist medications
    medications and relax airway smooth
    oxygen, per muscles and cause
    doctor’s orders. bronchodilation to
    open air passages.
    2. Maintain a clear -Encouraging the
    airway. patient to mobilize
    their own secretions
    via effective
    coughing facilitates
    adequate clearance
    of secretions.
    3. Place patient -A sitting position
    with proper body permits maximum
    alignment for lung excursion and
    maximum chest expansion.
    breathing
    pattern.

    Edx:
    1. Encourage -This method
    diaphragmatic relaxes muscles
    breathing for and increases the
    patients with patient’s oxygen
    chronic disease. level.
    2. Educate patient -These allow
    or significant sufficient
    other on proper mobilization of
    breathing, secretions.
    coughing, and
    splinting
    methods.
    3. Encourage small -Encourage small
    frequent meals. frequent meals.

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