ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: • Ineffective airway • After 4 hrs. Of nursing Independent: • After 4 hrs. Of nursing
1. Assist patient to 1. Elevation of the head
“Nahihirapan ako clearance related to interventions, the client interventions, the client
assume position of of the bed facilitates
huminga” as verbalized increased production of will demonstrate comfort, e.g., elevate respiratory function by was able to demonstrate
head of bed, encourage use of gravity.
by the patient. secretions. behaviors to improve behaviors to improve
patient to lean on
airway clearance. e.g. overbed table or sit on airway clearance. e.g.
the edge of the bed.
Objective: cough effectively and cough effectively and
• Use of accessory expectorate secretions. 2. Keep environmental 2. Precipitators of expectorate secretions.
pollution to a minimum, allergic type or
muscle.
e.g., dust, smoke and respiratory reactions
• Dyspnea feather pillows, that can trigger or
according to individual exacerbate onset of
Productive cough
situation. acute episode.
• V/S taken as follows:
3. Encourage or assist 3. Provides patient with
with pursed lip some means to cope or
T: 36.7 breathing exercises. control dyspnea and
reduce air trapping.
P: 57
R: 25 4. Administer 4. A variety of
medication as medications may be
Bp: 100/80
prescribed by the used to decrease mucus
physician. and to improve
respiration.

5. Provide supplemental 5. Humidity helps

humidification like reduce viscosity of
nebulizer. secretions, facilitating
expectoration, and may
reduce or prevent
formation of thick
mucus plugs in
bronchioles.

Patient:
Diagnosis: