NURSING DIAGNOSIS
________________________
GOALS
________________________
INTERVENTIONS
________________________
RATIONALE
________________________
EVALUATION
________________________
Potential ineffective airway
clearance R/T non-productive
cough and effect of
anesthetics.
Short-term:
Client’s lung sounds will
remain clear during my shift.
1. Ensure client knows how
to cough and deep-breathe
effectively and explain the
importance of it to them.
1. Will encourage client to
participate in the coughing
and deep-breathing.
Client’s lung sounds remained
clear throughout my shift.
2. Assist client with coughing
and deep-breathing about
10 times q1-2 h while
awake.
2. Will aid in the removal of
secretions and will expand
lungs.
3. Provide for pain-relief
before having the client
cough and deep breathe.
3. To encourage cooperation
& a less painful experience.
4. Provide a minimum of 2500
ml. fluids per day.
4. Will help to liquefy
secretions and therefore
assist with removal.
5. Encourage the use of an
incentive spirometer 4-6
times every 1-2 hours.
5. Will help to expand the
lungs more fully.
6. Assist client to get out of
bed and ambulate a short
distance each shift.
6. Will increase respiratory
expansion.
7. Monitor breath sounds,
respiratory rate and depth
and temperature every 4
hours.
7. To detect early signs of
consolidation and/or
infection.
Long-term:
Client’s lung sounds will
remain clear throughout her
Hospitalization.
Client was able to DB and C
and use incentive spirometer
and had 1500 ml of fluid
intake.
NURSING DIAGNOSIS
________________________
GOALS
________________________
INTERVENTIONS
________________________
RATIONALE
________________________
EVALUATION
________________________
Alteration in comfort related
to pain in surgical incision as
evidenced by rating abd. pain
@ 8 out of 10 and grimacing
with movements.
Short-term:
1. Assess location, quality,
intensity and site of pain
throughout shift.
1. To allow for appropriate
intervention and
documentation.
Short-term:
2. Assess both verbal and nonverbal indicators of pain.
2. Both verbal and non-verbal
cues will indicate pain
intensity and relief.
3. Use pain-rating scale as per
hospital policy.
3. Provides accurate
determination of pain
intensity and relief.
4. Administer analgesics prn
and give promptly when
asked.
4. Provides pain relief,
decreases stress and
anxiety.
5. Teach splinting of abd.
area when coughing and
deep breathing, laughing or
sneezing.
5.Teaches client ways to help
decrease pain.
1. Client will verbalize pain
relief to tolerable level (23) 1 hour after given
analgesic.
2. Client will state that
changing positions and
ambulating is more
tolerable (2-3) by the end of
the shift.
Long-term:
1. Client will be able to
tolerate oral analgesics
instead of injections within
48 hours.
Client verbalized pain relief
with analgesics and stated pain
decreased to between 2-4 at
end of shift.
- Goal met.
6. Administer analgesics prior
to ambulation.
7. Teach client nonpharmacological pain relief
measures (eg. Distraction,
imagery).
8. Continually assess
effectiveness of pain relief.
6. Ensures ambulation as pain
free as possible, increases
likelihood client will agree
to ambulate again.
7. Teaches client alternative
pain relief measures if pain
meds not yet due.
8. Helps to ensure adequate
pain relief.
Long-term:
Unable to assess at this point.
Would assess in 48 hours.