ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Ineffective Airway STG: 1. Monitor VS 1. to assess baseline STG:

“nahihirapan ako Clearance related to After 6 hours of every 2 hrs. data. After 6 hours of
huminga dahil sa thick tenacious nursing 2. encourage patient 2.promotes maximal nursing
ubo ko”, as secretions and intervention, the to position in high- lung function. intervention, the
verbalized by the airway obstruction cliet will be able to Fowler’s or semi- cliet had been able
patient. as manifested by cough effectively Fowler’s positon. to cough effectively
shallow respiration, and clear own 3. turn patient every 3.repositioning and clear own
Objective: tachypnea and fever. secretions. 2 hrs and prn. promotes drainage secretions.
>inability to cough of pulmonary Goal was met.
effectively LTG: secretions and
>shallow After 5 days of enhances ventilation LTG:
respirations nursing to decrease potential After 5 days of
>febrile intervention, the of atelectasis. nursing
>anxiety client will maintain 4.teach client to 4.to help thin intervention, the
>restlessness patency of airway maintain adequate secretions. client maintained
>adventitious breath and will have clear hydration by patency of airway
sounds breath sounds. drinking at least 8- and had clear breath
>tachypnea 10 glasses of sounds.
>use of accessory fluid/day ( if not Goal was met.
muscle while contraindicated).
breathing 5. teach and 5.to conserve
supervise effective energy and to
coughing reduce airway
techniques. collapse.
.6. perform Chest 6.CPT techniques
Physical therapy. utilizes forces of
gravity and motion
to facilitate
secretion removal.
7. instruct on 7.promotes
splinting abdomen increased expiratory
with pillow during pressure.
coughing efforts.
. 8..monitor airway 8.requires if patient
for patency and cannot maintain
provide artificial airway patency.
airways as
warranted.
9. administer 9. to improve
bronchodilators as ventilation and
ordered. maximizes air
exchange.
10. instruct 10. may indicate
client/family to bronchial tubes are
notify nurse if the blocked with
client is mucus, leading to
experiencing hypoxia and
shortness of breath hypoxemia.
or air hunger.
11. instruct 11. promotes
client/family prompt
regarding identification of
medications, effects, potential adverse
side effects and reaction to facilitate
symptoms of timely intervention.
adverse effects to
report to nurse or
physician.