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GOALS/
CUES/ NURSING NURSING
RATIONALE EXPECTED RATIONALE EVALUATION
ASSESSMENT DIAGNOSIS INTERVENTION
OUTCOMES
Subjective data: Ineffective airway Ineffective airway Within 8º of rendering INDEPENDENT: After 8º of rendering
clearance related to clearance is an inability nursing care, the patient nursing care, the goals
The mother verbalizes: pneumonia as evidence to clear secretions or will demonstrate: 1. Assess 1. Tachypnea, was partially met as
by fast breathing, obstructions from the rate/depth of respiration shallow respirations evidenced by:
increase and changes in respiratory tract to Decrease in rate and chest movement. and asymmetric chest
“Ginahapo and bata movement are
ko.” rate and depth of maintain a clear airway. and depth of Decrease in rate
respiration, cough, frequently present
respiration and depth of
dyspnea and nasal because of discomfort
Objective data: respiration
of moving chest wall
flaring. Absence of and or fluid in lung.
Fast Breathing dyspnea
Increase and 2. Elevate 2. Lower diaphragm,
changes in rate head of bed or assist promoting chest
patient in a semi- expansion, aeration of
and depth of
fowler’s position with lung segments,
respiration mobilization and
pillow support.
Cough expectoration of
Dyspnea DEPENDENT: secretions.
Nasal flaring
T= 35.80C 1. Assist with/ monitor 1. Facilitates liquefaction
and removal of
P= 96 beats/min effects of nebulizer
secretions.
RR= 60 cycles/min treatments and other
respiratory
physiotherapy.