Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Ineffective Short term Elevate head -promotes After 30

“hinahapo ang breathing goal: up to 30 respiratory minutes of
paghinga ko” pattern related After 30 degrees from function by the nursing
as verbalized to thick mucus minutes of the bed and use of gravity intervention,
by the client. secretions. nursing position the also decrease client was able
intervention, client in dorsal pressure on to experience
Objective: client will recumbent the abdomen. lessened
RR- 24 experience position. difficulty of
Restlessness lessened breathing as
Rapid shallow difficulty of Encourage -promotes lung manifested by
breathing breathing as deep breathing expansion. decreased in rr
Mucous manifested by exercises. from 24 bpm
secretion decreased in rr to 20bpm.
from 24 bpm Keep -to avoid
to 20bpm. environment triggering the After 8 hours
free from episode of of nursing
Long term pollution. cough. intervention
goal: patient was
After 8 hours Increase fluid -helps in able to
of nursing intake clearing and expectorate
intervention liquefy phlegm as
patient will secretions. proven by a
expectorate relief in
phlegm as Dependent: breathing.
proven by a
relief in Administer -helps relieve Thus goal was
breathing. medications as the symptoms. met.
prescribed