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Subjective: Ineffective airway Within 1 hour of 1. Maintain adequate 1. To prevent further aggravation / After an hour of
clearance r/t airway nursing patent airway complication. nursing intervention,
“Nahihirapan akong
spasm and allergic intervention, • Keep client in a wide • Improve air ventilation, reduce the client was able to
huminga” as airways the patient will space, allergen-free anxiety and prevent further demonstrate improved
be able to environment aggravation. air exchange as
verbalized by
maintain airway depending on the • Semifowler position helps evidenced by:
patient. OR patency individual situation. RR=12-20 breaths per
maximize lung expansion and
demonstrating Open the doors and ventilation. This position uses gravity minute
Impaired gas exchange absence or windows or keep to pull the diaphragm downward PR=60-100 bpm
Objective: r/t decreased airway reduction of bystanders away. BP=120/80
diameter breathing. • Assist client in a • Orthopneic position is helpful Normal breathing /
distant adventitious for clients who have problems
semi-fowler or lung sound.
sounds heard by orthopneic position. exhaling. This position allows Client was also able
INFERENCE maximum lung expansion and then to expectorate phlegm
auscultation, Triggering factors of allows the client to press his/ her and verbalized
wheezing, coughing, asthma causes 2. Mobilize secretions lower part of the chest against the “Nakakahinga na ako
inflammation of the head of the overbed upon exhaling. ng maluwag”
use of accessory airways which leads to
• Encourage and
instruct the client to
2. Deep breathing exercises and coughing
muscle while contraction of the helps remove secretion from airways.
bronchial smooth muscle. perform breathing
and coughing • (To follow: Drug study) This is
breathing, difficulty This will reduce the
exercise. a dependent nursing action
vocalizing, presence airway diameter and • Nebulizers or steam delivers a
excessive mucus • Give medicines as
prescribed by doctor fine spray of medication or moisture
of sputum production. to client. It dilates the airways and
RR=40 breaths per • Provide loosens mucous secretions
Inability to clear humidification,
minute secretions and obstruction nebulizer/ steam
PR=110 bpm from the respiratory tract inhalation with saline
will lead to difficulty of solution
BP=130/100 breathing, decreased
oxygenation, air hunger,

Reference: NANDA, Brunners and Suddarth, Kozier, Pearson’s Pathophysiology