Date/ Assessment Need Nursing Objective of Nursing Intervention Evaluation

Time Diagnosis Care

January 31, Subjective: P Ineffective Within 4 hours Independent: Goal Met, within 4
2017 Naagihapon koy H Airway Clearance of nursing care, 1. Established rapport. hours or nursing
ubo maam, Y r/t retained effective airway To establish trusting care effective
73 shift maglisod ko ug S secretions in the clearance will relationship. airway clearance
hinga pero I tracheobronchial be observed as 2. Monitored and recorded is observed as
7am arang- arang na O tree s/t COPD evidence by: V/S. evidenced by:
kay wala nako L To have baseline data
naka oxygen, O COPD >maintained and note any unusualities. > maintained
pero na ako G respiratory rate 3. Instructed to increase respiratory rate
paaso nga I within normal oral fluid intake. within normal
tambal as C range Hydration helps the range
verbalized N viscosity of secretions. (12nn/ RR-20bpm)
E >cough 4. Monitored respiratory
Objective: E effectively and rate, depth and effort. >coughed
>cough out with S expectorate Respirations may be effectively and
scanty amount / secretions shallow and rapid. expectorate
of whitish O 5. Auscultated lung sound secretions
phlegm X >increase oral before and after shift .
>flaring of Y fluid intake to know and assess >increase oral
nostrils & use of G (8-10glasses/ abnormal lung sound. fluid intake is
accessory E day) 6. Encouraged deep observed
muscles not N breathing and coughing (Sige nako inum
noted A exercises. ug tubig maam
>no adventitious T to promote proper lung mga is aka litro
sound heard I expansion. na ako nahurot
upon O 7. Positioned on MHBR. karon as
auscultation N Helps reduce muscle verbalized)
>coughed at fatigue and can aid chest
times expansion.
 8. Kept environment free
V/S from irritants/dust.
BP-120/80mmHg it could trigger the onset
T-36.6 of allergic reactions.
PR-76bpm
RR-20cpm
O2 Sat-96%
Capillary Refill- 9. Observed characteristics
< 2 seconds of persistent cough.
cough can be persistent
but ineffective.

Dependent:
1. Administered
bronchodilator meds
(Ipatropium+ Salbutamil1
neb q2) as order.
To relieve bronchospasm.

Collaborative:
1. Instructed watcher to
keep accompany the
patient or be at bedside.
to provide and assist
patients need.
2. Instructed watcher to
comply treatment regimen.
To help maintain proper
therapeutic regimen.
 Date/ Assessment Need Nursing Objective of Nursing Intervention Evaluation
Time Diagnosis Care
January 31, Subjective: P Imbalanced Independent:
2017 H Nutrition: Less
Y Than Body
73 shift S Requirements r/t
I
8am O
L Dependent:
O
G
Objective: I
C
N
E
E
S Collaborative:
/
 Date/ Assessment Need Nursing Objective of Nursing Intervention Evaluation
Time Diagnosis Care
January 31, Subjective: P Readiness for Within 1 hour of Independent: After 1 hr of
2017 Unsa akung H enhanced effective 1. Assessed perceptions nursing care. Goal
Y
dapat diay Knowledge: nursing of current health problems met as evidenced
S
73 shift buhaton I
Health intervention will Indicate deficient by:
maam? as O be able to knowledge or
9am verbalized L Rationale: verbalize misinformation. Mao jud mam
O Demonstration understanding dapat mag
Objective: G of behaviors or of the 2. Determined amping najud ko
I cues that reflect information motivation/expectations for sa akong pa
C
He manifested: the learners gained. learning lawas ani labi
N
-cooperation E motivation to To develop plan for najud na
E learn at a learning. ngkatiguwang
- follows S specific time. nata ani para dli
instructions / Reflects not only 3. Provided information mas molala ug
S the desire or about additional learning maayo akong
E
- active listener willingness to resources. Such as:-books- sakit, salamat
L
F learn but also magazines- t.v programs. kayo maam as
- shows positivity the ability to Promotes ongoing verbalized
towards the A learn at specific learning at own pace.
C
treatment time.
T
U
4. Ascertained preferred
- asking A Reference: methods of learning
about the normal L Fundamentals of To facilitate learning
condition of his I Nursing 8th process.
health Z edition, by Kozier
A and Erbs, page 5. Instructed to avoid
T
-asking about 49. smoking and stay away
I
the possible O from secondhand smoke.
outcomes of N to prevent further
health complications.

Dependent :
1. Encouraged to comply
treatment regimen as
prescribed such as home
medications
To facilitate in treatment
management ma

Collaborative:
1. Reinstructed watcher to
pecific dietary changes/
restrictions
To promote wellness.
2. Instructed watcher to
comply treatment regimen.
To help maintain proper
therapeutic regimen.