Cues Nursing diagnosis Objectives Nursing intervention Rationale Evaluation

GENERAL OBJECTIVES:  Monitor vital  To have a baseline

SUBJECTIVE DATA: Ineffective airway To facilitate the signs data and for Goals partially met as evidenced
“Ginabudlayan imaw clearance related to maintenance of the especially future by patient cough continue to be
magpaguwa sa anang bronchoconstriction, supply of oxygen to all respiratory comparison.
plema.” as verbalized by body cells. productive with moderate thick,
and increased rate.
the mother. yellowish sputum. Wheezing
mucus production
SPECIFIC OBJECTIVES: remains presents during
OBJECTIVE DATA:
as evidenced by
After 1 hour of nursing  Promote
wheezing, and systemic fluid  To liquefy inspiration.
intervention the patient
cough with hydration, as secretions and
 Nasal flaring will be able to
yellowish phlegm. appropriate facilitates
 Wheezing heard expectorate phlegm
expectoration of
on both lungs
upon auscultation  Coach and mucus.
encourage the  These techniques
 Productive cough
use of help to improve
with yellowish
diaphragmatic ventilation and
sputum
breathing and mobilize secretion
 Dyspnea
coughing without causing
exercise breathlessness
 Use of accessory
 Avoid milk and and fatigue.
muscles in
milk product.  Milk products
breathing
tends to thickens
 Positioning secretions.
 Tachypnea
the client.
prolonged  To allow
Elevate the
expiration maximum chest
head of the
 Chest tightness expansion
bed in fowlers
position or
sitting
 position

 Instruct the  Bronchial irritants

mother to causes
avoid bronchoconstricti
exposing the on and increased
client to mucus production
irritants like which interfere
cigarette with the airway
smoke, clearance
aerosols, dust,
fumes and
extremes of
temperature
 prevents over
 Promote bed
exhaustion and
rest
reduced oxygen
consumption

DEPENDENT:
 Administer  Bronchodilator
Salbutamol reduces
and bronchospasm; it
ipratroprum opened congested
bromide airways and
nebulization ½ facilitating
q20mins x 3 ventilation.
doses as
prescribed by
 the physician.

 Administer  Corticosteroid
hydrocortison suppress the
e inflammatory
40mg response in the
/IVTT/q6h airways by
decreasing
synthesis and
release of
inflammatory
mediators,decreas
ing activity of
inflammatory
cells,and
decreasing
edema.
COLLABORATIVE:

 Maintain
 To provide for
oxygen
adequate
administration
oxygenation and
device as
humidifier
ordered, with prevents mucus
humidifier
membrane from
drying and
becoming irritated
and loosen
secretions for
 easier
expectoration
 Use pulse
oximetry to  . Pulse oximetry is
monitor a useful tool to
O2 saturation detect changes in
and pulse rate oxygenation.
continuously. O2 saturation
should be
maintained at
95% or greater.
 Initiate the
use of  It helps loosen
Incentive respiratory
Spirometer secretion and
expand collapse
alveoli
 Initiates
 These helps
physiotherapy
loosen thick
as ordered
secretions.
such as back
tapping,
percussion
and vibration.