Cues Nsg.

Diagnosis Rationale Goals Intervention Rationale Evaluation

Subjective: Ineffective Airway Pleural Effusion is After 2 days of 1. Established 1. To gain the The client had
“Nakukurian aq clearance related an accumulation nursing rapport. trust and improved airway
paghinga ngan to excessive of fluid in the intervention, the cooperation of the clearance as
paguubo tungud secretions and pleural space. client will have client.
evidenced by a
hit akon mga ineffective Pleural fluid improved airway
plema”as coughing normally seeps clearance as 2. Assist patient to 2. Lying flat patent airway and
verbalized by the continually into evidenced by a sitting position causes the effective coughing
client. the pleural space effective coughing with head slightly abdominal organs techniques.
from the techniques and a flexed, to shift toward the
Objective: capillaries lining patent airway. shoulders relaxed, chest,
the parietal pleura and knees flexed. crowding the
•febrile and is reabsorbed lungs and making
by the visceral it more difficult to
•tachypneic pleura capillaries 3. Monitored lung breathe.
and lymphatic sounds every 4 to
•pale system. Any 8 hours and 3. Rhonchi
condition that before and after present in the
•use of accessory interferes may coughing large airways may
muscles lead to dyspnea, episodes. impair airway
and difficulty patency
•inspiratory breathing and 4. Monitored rate,
crackles with coughing. rhythm, depth,
diminished and effort of
breath sounds respirations. 4. Provides a basis
for evaluating
•expectorating 5. Taught the adequacy of
thick, client to maintain ventilation.
yellow sputum adequate
hydration by 5. Hydration helps
Heart rate – 74 drinking at least 8 to thin secretions.
Bpm to 10 glasses of
RR – 26 cpm fluid per day(if not
BP – 130/80 contraindicated).
mmhg
Temp – 39.4 C

6. Taught and
supervised 6. Proper
effective coughing coughing
techniques techniques
conserve energy,
reduce airway
collapse and
7. Taught and lessen client
supervised frustration
incentive
spirometer 7. Incentive
techniques 10 spirometer is an
times per hour objective measure
while awake. of the depth of
inhalation to
promote lung
8. Encouraged her expansion
to take several
deep breaths. 8. Deep breathing
promotes
oxygenation
9. Performed before controlled
chest physical coughing.
therapy, if
needed, and 9. Chest physical
instruct the client therapy
and significant techniques use
others in this forces of gravity
technique. and motion to
facilitate secretion
10. Assessed the removal.
condition of the
oral mucous 10. Thick
membranes and secretions line the
perform or offer mouth when the
oral care every 2 client coughs; oral
hours care removes
them.
Objectives:

After the ward class the students are able to:

1. Discuss the Client’s Nursing Health History.

Identify the risk factors associated with Uremic Encephalopathy

2. Review the Anatomy and Physiology of the Urinary System &

Neurologic System

3. Relate the Laboratory Results to the disease process.

4. Discuss the Pathophysiology of Uremic Encephalopathy.

5. Discuss the comprehensive Nursing Care and Discharge Plan.

6. Discuss the General Action, Specific action, Indications, Contraindications, Adverse Effects &

Nursing Responsibilities for each drug.