HUMAN

RESPONSE
E
X
C
H
A
N
G
I
N
G

NURSING
DIAGNOSIS

CUES/AMB

Ineffective airway
clearance r/t
inability to cough
out 2 toddler status

SUBJECTIVE:
napapasin kong
mabilis ang kanyang
paghinga at inuubo rin
siya atska hindi nia rin
malabas ang plema
pagumuubo siya as
verbalized by the
mother.
OBJECTIVE:
Patient manifested:
>RR-74 bpm
>crackles were noted
upon auscultation
>sunken eye balls
>crack and dry lips

CLIENT OUTCOME

Within the 8hrs of the

shift the patient able to
less crackles noted and
the respiratory rate will
be stable and have no
manifest of repiratory
distress

INTERVENTION

Establish rapport to the

patient
assess the patient s
condition
monitored and record
VS
auscultate lung fields,
noting areas of
decreased/absent
airflow and
adventitious breath
sounds
assist patient to change
position every 30
minutes
elevate head of bed and
align head in the
middle
provide health teachings
regarding effective
coughing and
breathing exercises
encourage to increased
fluid intake at a
tolerable level

RATIONALE

to gain trust of
the patient
to know and
determine
patients needs
to establish
baseline
to identify
consolidation
and determine
possible
bronchospasm
or obstruction.
to mobilize
secretions
to facilitate
breathing
to expel the
mucous
to liquefy
secretions
to moisten
secretions and
alleviate
congestion
to reduce
bronchospasm

EVALUATION

 encourage steam
inhalation
administer meds as
ordered

and mobilized
secretion.