NURSING SCIENTIFIC

ASSESSMENT PLANNING INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS EXPLANATION
Subjective: Ineffective Airway Irritant (Inhalation) Long Term - Encourage deep - This will promote Long Term
“Hindi siya Clearance related Outcome: breathing exercise. proper lung Outcome:
masyadong to Excessive After 1 week of expansion. GOAL ACHIEVED,
makahinga dahil sa Secretions as Inflammatory nursing The client was able
sipon niya.” As evidence by Stuffy Response interventions, the - Position head - To open or to demonstrate
verbalized by the Nose, Nasal client will be able midline with flexion maintain open absence or
client’s mother. Flaring and Use of to demonstrate appropriate for age airway in at-rest or reduction of
Increase
Accessory Muscle. absence or or condition. compromised congestion with
Production of
Objective: reduction of individual. breath sounds
Secretions
- Sneezing congestion with clear, respirations
- Stuffy nose breath sounds - Provide - To examine and noiseless,
- Use of accessory Airway Constriction clear, respirations information about report changes in improved oxygen
muscles when noiseless, the necessity of color and amount. exchange.
breathing improved oxygen raising and
Colds (Common
- Nasal flaring exchange. expectorating
Colds)
- Mouth breathing secretions versus Short Term
- RR: ?cpm swallowing them. Outcome:
Short Term GOAL ACHIEVED,
Outcome: Collaborative: The client’s mother
After 8 hours of - Administer - Prescribed was able to
Reference:
nursing prescribed medications such verbalize
Foundations of
interventions, the medications. as bronchodilators understanding of
Nursing
client’s mother will helps in aiding cause and
By: Lois White
be able to effective airway therapeutic
verbalize clearance. management
understanding of regimen.
cause and - Provide - Nebulization
therapeutic supplemental helps in liquefying
management humidification via secretions for
regimen. use of nebulizer. better and faster
expectorating the
secretions.