Diagnosis # 2

Need

Desired Outcome Within 8 hrs of nursing interventions:

Nursing Interventions

Rationale

Evaluation Statement

Ineffective Airway Clearance r/t retained secretions as manifested by dyspnea Subjective: dili ko ka ginhawa Objective: rales are evident upon auscultation dyspnea scale of 8 from scale of 0-10 V/S: BP = 140/90mmHg RR = 29 cpm CR = 52 bpm P= 56 bpm Background Knowledge The diastolic dysfunction (backward effects) of LFH results from the

P H Y S I O L O G I C

Patient will demonstrate improved ventilation airway patency Patient will expectorate secretions

Independent Evaluate change in level of mentation. Note cyanosis and change in skin color, including mucous membranes and nail beds Assess energy level and activity tolerance.

Accumulation of fluids/airway compromise can impair oxygenation of vital organs and tissues.

To determine choice of interventions and provides basis for comparison and evaluation of therapy. Reduces oxygen consumption/ demands and promotes maximal lung inflation

Goal partially met. Client verbalized, makaubo-ubo na ko pero gamay pa lang ang akoang mapagawas. Pero masulti nako na nag-improve jud siya.

Maintain chair/bedrest with head of bed elevated 20-30 degrees, semi-fowlers position. Support arms with pillows Encourage frequent position changes

Helps prevent atelectasis and

volume overload of the left ventricle or in some cases the left atrium. Because the left heart cannot discharge its normal ejection fraction, increased enddiastolic volume causes blood to accumulate in the left atrium, into the four pulmonary veins, and the pulmonary capillary bed (PCB). As the volume of blood in the lungs increases, the pulmonary vessels enlarge. The pressure of blood in the PCB increases. When it reaches a certain critical point (about 25-28 mm Hg), fluid passes across the pulmonary capillary membrane into the interstitial spaces around the alveoli and finally into the alveoli. Actual

pneumonia Instruct patient In effective deep breathing and coughing exercises Promotes optimal chest expansion and drainage of secretions thus, facilitates oxygen delivery Use of a scale to evaluate dyspnea helps clarify degree of difficulty and changes in condition.

Assess for dyspnea.

Specific Report patency in the airway

Auscultate breath sounds, noting crackles, wheezes

Promote bedrest/limit activity and assist with self-care activites

Goal partially met Patient report Reveals presence of that dyspnea pulmonary was reduced . congestion/collection of Patient secretions, indicating verbalized that need for further the phlegm is intervention. still present but has reduced in Reducing oxygen amount due to consumption/ demand his persistent during periods of coughingt has respiratory compromise may reduce severity of symptoms. To reduce irritant effect on airways.

Keep environment allergen/pollutant free

alveolar pulmonary edema occurs when the rate of fluid transudation exceeds the ability of the plentiful lymphatic drainage to remove it from the interstitial spaces. Acute pulmonary edema (APE) results as the alveoli fill with fluid; this impairs gas exchange. Impaired gas exchange refers to excess or deficit in oxygenation and/or carbon dioxide elimination at the alveoli-capillary membrane (this may be an entity of its own but also may be an end result of other pathology with interrelatedness between airway clearance and/or breathing pattern problems.

Collaborative Administer supplemental oxygen as indicated Increases alveolar oxygen concentration, which may correct/ reduce tissue hypoxemia Reduces alveolar congestion, enhancing gas exchange. Increases oxygen delivery by dilating small airways and exerts mild diuretic effect to aid in reducing pulmonary congestion.

Administer medication as indicated: Diuretics, e.g., furosemide

Maintain adequate I&O but avoid fluid overload Encourage adequate rest and limit activities within client tolerance. Promote calm, restful environment.

For mobilization of secretions Helps limit oxygen needs/consumption.

Patient will Verbalize and demonstrate understanding of methods in

Goal met

maintaining patency of the airway

Demonstrate deep breathing exercises

Creates resistance against outflowing air to prevent collapse/narrowing of airways, thereby helping distribute air throughout the lungs and relieve/reduce shortness of breath.

Patient able to verbalize eagerness to participate in the treatment regimen as well as the methods in improving his airway.

Provide psychological support, listening to questions/ concerns. Review oxygenconserving techniques (e.g. sitting instead of standing to perform tasks, eating small meals:performing slower purposeful movements. Reinforce treatment rationale. Include significant others in teaching as appropriate.

This will aid in decreasing of anxiety and increase patients self-esteem. Knowledge of disease process and expectations can facilitate adherence to prescribed treatment regimen.

Patient will participate in treatment regimen

Patient may believe it is acceptable to alter postdischarge regimen when feeling well and symptom-free or when feeling below par,

Review safe use of medications, purpose and side effects requiring medical evaluation. Provide oral and written instructions.

which can increase the risk of exacerbation of symptoms. Understanding of regimen, medications and restrictions may augment cooperation Goal met with control of patient able to symptoms. understand Understanding of the purpose of therapeutic needs and the drugs importance of prompt given to him reporting of side effects and was can prevent occurrence encouraged to of drug-related take them as complications. Anxiety prescribed may block comprehension of input or details and patient/significant others may refer to written material at alter date to refresh memory.