Nursing

Cues Nursing Diagnosis Inference Objective Rationale Evaluation

Intervention

Subjective ◊ Ineffective airway ◊ Due to the trauma Short Term Goal Independent ◊ After 10 minutes of
clearance r/t lung that has occurred over ◊ Maintained an open ◊ Provides for nursing intervention,
◊ “Nahihirapan siya impairment the ribs, an intense ◊ After 10 minutes of airway. adequate ventilation goal is met through
na huminga inflammatory response nursing intervention, and gas exchange the patency of airway,
pagkatapos nung occurred. Exudation of patent airway is ◊ Performed ◊ Endotracheal demonstration of
aksidente na plasma, leukocytes, achieved & there is endotracheal secretions are present effective exercises
nangyari” as infiltration of mast improvement in the suctioning until she in excessive amounts when coughing &
verbalized by sister. cells, growth factors airway clearance. can raise secretions in post-thoracotomy lungs are clear on
and inflammatory effectively. patients due to trauma auscultation.
Objective leukocytes occurs in to the tracheobronchial
effect. These fluid and tree during surgery,
◊ use of accessory exudates crosses the diminished lung
muscles during permeable membrane ventilation and cough
inhalation & expiration of the pleurae causing reflex.
it to accumulate in this
◊ Pain was assessed. ◊ Helps to achieve
◊ restlessness membranous space.
Encouraged deep maximal lung inflation
Instead of the lungs
breathing and and to open closed
◊ c chest tube intact being able to function
coughing exercise. airways.
& draining to dark red normally, these fluids
exudates inhibit the lungs to ◊ Amount, viscosity, ◊ Changes in sputum
expand color and odor of suggests presence of
◊ draining output is anteroposteriorly thus sputum were infection or change in
moderate in amount causing ineffective monitored. pulmonary status.
breathing Opacisication or
◊ V/S as follows: & discomfort. coloration of sputum
T= °C may indicate
P= bpm dehydration or
R= cpm infection otherwise.
BP= / mmHg ◊ Performed postural ◊ Chest physiotherapy
drainage, percussion uses gravity to help
and vibration as remove secretions
prescribed. from the lungs.
◊ Determined changes ◊ Indications for
in breath sounds tracheal suctioning are
through auscultation. determined by chest
auscultation.
Dependent ◊ Secretions must be
◊ Administered moistened and thinned
humidification & if they are to be raised
nebulizer therapy as from the chest with
prescribed. the least amount of
effort.
 Nursing
Cues Nursing Diagnosis Inference Objective Rationale Evaluation
Intervention

Subjective ◊ Acute Pain r/t ◊ Acute pain is Short Term Goal Independent ◊ After 30 minutes of
incision, drainage described as an nursing intervention,
◊ “Kumikirot pa ang tubes & surgical unpleasant sensory or ◊ After 30 minutes of ◊ Location, character, ◊ Pain limits chest the goal is met
naoperahan sa kanya procedure emotional experience nursing intervention, quality and severity of excursion and thereby through the patient
kaya siya di makausap associated with actual pain intensity as pain was evaluated. decreases ventilation. verbalizing that she is
at makatulog mabuti,” or potential tissue verbalized will be free of acute distress
as verbalized by damage or injury as lessened from 7/10 to ◊ Maintained care in ◊ The patient who is and feels much more
sister. lasting from seconds to 4/10. positioning the patient. comfortable and free comfortable. There is
6 months. In cases of Placed in a semi- of pain will be less no sign of incisional
Objective fracture, pain is Fowler’s position & likely to splint the infection.
continuous & turned every 2 hours. chest while breathing.
◊ positive facial increasing in severity A semi-Fowler’s
grimace but will subside position permits
significantly on the 5th residual air in the
◊ weakness to 7th day. Pain may be pleural space to rise to
attributed to the upper portion of
◊ pain intensity is increase of pressure pleural space and be
7/10 caused by the increase removed.
production of exudates
◊ irritable thus causing pain ◊ Incision area was ◊ These signs indicate
radiating over the site. assessed every 8 hours possible infection.
◊ V/S as follows: for redness, heat,
T= °C induration, swelling
P= bpm and drainage.
R= cpm
BP= / mmHg Dependent

◊ Administered ◊ Analgesics give pain

analgesics as relief on the part of
prescribed. the patient.
 Nursing
Cues Nursing Diagnosis Inference Objective Rationale Evaluation
Intervention

Subjective ◊ Impaired physical ◊ Impaired ability to Short Term Goal Independent ◊ After 3 days of
mobility of the perform dressing & nursing intervention,
◊ “Hindi siya gaano upper extremities toileting as part of ◊ After 3 days of ◊ Patient was ◊ Necessary to regain goal is met through
makakilos gawa nung r/t thoracotomy activities of daily living nursing intervention, assisted with normal normal mobility of arm the regaining of the
mga nakalagay sa is due to contraptions she demonstrates and range of motion and and shoulder to speed patient’s previous
kanya,” as verbalized within the abdominal verbalizes proper function of shoulder recovery. range of motion in the
by sister. area. Movement is exercises of the upper and trunk. Proper shoulders and arms &
limited and often is extremities & can breathing exercises to demonstrates proper
obstructed by the perform activities of mobilize thorax were exercises for the
Objective tubings. daily living gradually.. advised. upper extremities. She
◊ Increase patient’s also does ADL without
◊ c chest tube ◊ Encouraged use of affected discomfort.
drainage on L lateral progressive activities shoulder and arm.
abdomen according to level of
fatigue.
◊ restlessness