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Assessment Diagnosis Planning Intervention Rationale E

Subjective Data: Ineffective airway After 8 hours of nursing Independent: GOAL PA
clearance related to interventions, the patient Assessed vital signs To serve as a baseline data After 8 ho
“Inuubo siya pero dry”, retained secretions will be able to: and check the general interventi
as verbalized by the characterized by condition of the patient verbalized
mother. unproductive cough - Maintain airway better but
patency This is to ensure that the unproduc
Objective Data: - Expectorate secretions Monitored and client is receiving the right there is a
regulated IVF amount of IV fluid, and to reassessm
VS taken accordingly prevent complications of IV plan of ca
T: 38.0*C infusion
RR: 33
PR:130 To meet the patient’s
O2 Sat: 98% comfort needs

Promoted rest Hydration can help improve

secretion clearance

Instructed the mother

and the client to
increase oral fluid
intake and avoid cold For treatment

medication as ordered
by the physician