Cues Nursing Scientific Objectives Nursing Rationale Evaluatio

Diagnosis Explanation Interventio n

ns
S> Ineffective Because of After 2 hours > Monitor >Rhonchi
Airway excessive of nursing lung sounds present in
O > Dyspnea Clearance mucus interventions, every 4-8 the large
> related to secretions, the patient hours and airways may
excessive the will be able before and impair
secretions secretions to have after patency.
and are being improved coughing
ineffective trapped in airway episodes.
coughing. the lungs clearance as >Hydration
causing evidenced by >Teach the helps to
inadequate effective client to reduce
air that coughing maintain secretions.
comes and technique adequate
out of the and a patent hydration by
lungs. airway drinking 8 to
10 glasses of
fluids each
day (if not
contraindicat
ed) and
increasing
the humidity
of the >Proper
ambient air. coughing
techniques
>Teach and conserve
supervise energy,
effective reduce
coughing airway
techniques. collapse and
 lessen
client’s
frustration.

> Perform > Chest

chest physical
physical therapy
therapy, if techniques
needed, and use forces of
instruct the gravity and
client and motion to
significant facilitate
others in secretion
these removal.
techniques.
> Thick
>Reassess secretions
the condition line the
of the oral mouth when
mucous the client
membranes coughs; oral
and perform care removes
or offer oral them.
care every 2
hours.
Cues Nursing Scientific Objectives Nursing Rationale Evaluatio
Diagnosis Explanation Interventions n
S> Φ Impaired Gas In After 2 hours >Regularly > Prompt
exchange emphysema, of nursing monitor the recognition
O> Dyspnea related to there is interventions client’s of
> RR: decreased destruction , the client respiratory rate deteriorating
> PR: ventilation of the will be able and pulse respiratory
and mucus connective to maintain oximetry, ABG function can
plugs tissue adequate results, and reduced
responsible gas manifestations potentially
for much of exchange. of hypoxia or lethal
the elastic hypercapnia. outcomes.
recoil of the Report
lung significant
resulting to changes or
shortness of lack of
breath. response
promptly.
> Oxygen
> Administer corrects
low flow existing
oxygen hypoxemia.
therapy (1 to 3 Excessive
L/min or 24 % increases in
to 31% Flo2) as o2 (55% to
needed via 70% Flow)
nasal prongs or may diminish
a high-flow respiratory
venture mask. drive and
increases
carbon
dioxide
 retention
further.
> During >
episodes, open Environment
doors and al changes
curtains and may lessen
limit the the client’s
number of perception of
people and suffocation.
unnecessary
equipment in
the room.
Provide a fan if
the client
perceives a
benefit from
the moving air. > A feeling of
self control
> Encourage and success
the use of in facilitating
breathing breathing
retraining and helps
relaxation reduced
technique. anxiety.

> Over
> Give sedation may
sedatives and cause
tranquilizers respiratory
with extreme depression.
caution,
nonpharnaceut
ical method of
anxiety are
useful.
Cues Nursing Scientific Objectives Nursing Rationale Evaluation
Diagnosis Explanatio Interventions
n
S Activity Insufficient After 4 hours >Evaluate client’s >Provides
O > Easy intolerance physiologic of nursing actual and comparative
fatigability related to al or intervention, perceived baseline and
>Supported psychologic the patient will limitations in light provides
actions when al energy to identify of usual status information about
moving endure or negative needed
complete factors interventions
required or affecting regarding quality
desired activity of life.
daily tolerance and >Ascertain ability
activities eliminate or to stand and >To determine
which could reduce their move about and current status and
be related effects when degree of needs associated
to any possible. assistance or with participation
discomfort necessary use of in needed or
that the equipment desired activities.
patient
feels. >Adjust activities >To prevent
to patient’s own overexertion
capability

>Teach methods >To conserve

to increase energy and
activity levels reduce fatigue
gradually and
plan care with
balanced rest
periods.
>Helps to
>Provide positive minimize
atmosphere and frustration and
diversional rechannel energy
activities.
>To protect client
>Teach client from injury
with the use of
assistive devices
>To enhance
>Promote comfort ability to
measures participate in
activities
>Assist client in
learning >To prevent
appropriate safety injury
measures
Cues Nursing Scientific Objectives Nursing Rationale Evaluation
Diagnosis Explanatio Interventions
n
S> Ineffective When a The client will 1. Frequently Early identification
Breathing stimulant be able to reassess of ineffective
O>With rapid Pattern trigger such establish an respiratory rate, respirations allows
and shallow related to as effective pattern, and breath timely initiation of
respirations bronchospas inhalation respiratory sounds. Note interventions.
m, of an pattern so as manifestations of
>Uses decreased allergen or to provide ineffective
accessory lung irritant adequate breathing.
muscles to aid expansion occurs, an ventilation as Tachypnea,
in breathing acute or manifested by 2. Monitor vital tachycardia, an
early stabilizing signs and elevated blood
>Exhibits response respiratory laboratory results. pressure, and
nasal flaring develops in rate, increasing
the decreasing hypoxemia and
hyperreacti chest hypercapnia are
ve airways tightness, signs of
predisposed slight to no compromised
to nasal flaring respiratory status.
bronchospa and
sm. decreasing 3. Assist with self- This conserves
Sensitized usage of care activities. energy and
mast cells accessory reduces fatigue.
in the muscles by 4. Provide rest
bronchial 04/20/10 3:00 periods between Scheduled rest is
mucosa p.m. scheduled activities important to
release and treatments. prevent fatigue
inflammator and reduce
y mediators 5. Place in Fowler’s, oxygen demands. .
such as High Fowler’s or
histamine, orthopneic (with These positions
prostagland head and arms reduce the work of
ins and supported on the breathing and
leukotrienes overbed table) increases lung
. These position to facilitate expansion,
mediators breathing and lung especially the
stimulate expansion. basilar areas.
parasympat
hetic 6. Teach and assist
receptors to use techniques
and to control
bronchial breathing pattern: Pursed- lip
smooth a. Pursed-lip breathing helps
muscle to breathing keep airways open
produce b. Abdominal by maintaining
bronchocon breathing positive pressure,
striction. c. Relaxation and abdominal
They also technique including breathing
increase visualization, improves lung
capillary meditation and expansion.
permeabilit others. Relaxation
y, leading techniques reduce
to mucosal anxiety and its
edema, and 7. Administer 2 effect on the
stimulate liters per minute of respiratory rate.
mucus oxygen as ordered.
production. Supplemental
8. Administer oxygen reduces
nebulizer hypoxemia.
treatments as
ordered.
Adrenergic
stimulants affect
 receptors on
smooth muscle
cells of the
respiratory tract,
9. Administer anti- causing smooth
inflammatory muscle relaxation
agents as ordered. and
bronchodilation.

These are used to

suppress airway
inflammation and
reduce asthma
symptoms. It
blocks late
response to
inhaled allergens
and reduce
bronchial
hyperresponsivene
ss.