Cues Diagnosi Desired interventions Rationale Evaluation

s Outcome
S: maglisod ko og Ineffective Within 8 hrs of - Monitor respiratory - Changes in the respiratory After 8 hours of nursing
ginhawa, ma’am” as Airway interventions, rate, depth, and rate and rhythm may interventions, patient was
stated by the patient Clearance Patient will able to maintain airway
rhythm indicate an early sign of patency as evidenced by
related to maintain airway impending respiratory
O: received patient lying Increased patency as
in the bed,awake and pulmonar distress. RR: 14 breathes/min
evidenced by
conscious with ongoing y PR: 90 bpm
clear breath
IVF #1 PNSS 1L secretions sounds, improved -monitor lung sounds - Wheezes suggest partial O2 Sat: 96%
-with clear breath clear
regulated at 30 gtts/min.
oxygen exchange, for adventitious breath obstruction or resistance.
-cough breath sound and effectivey
normal rate and sound While rhonchi may indicate cough out mucous secretions
-wheezing
depth of retained secretions in the
-SOB
With initial vital signs as respiration, and lungs.
follows: ability to
PR- 123b/min effectively cough - elevate patients’ bed
RR-28cpm out secretions.
BP-120/80 mmHg - Encourage client to use
Temp-37.7 pursed-lip breathing for -to facilitate mucosal
O2 Sat-94% exhalation movement

- chest tapping after

nebulization

- encourage increase - Provides information on the

fluid intake fluid balance of the patient.
Dehydration can contribute in
- Monitor and record viscous secretions and may
intake and output (I&O) result to decrease airway
adequately. clearance.
- Helps loosen and
expectorate excess secretions
and contribute in effective
- Encourage deep clearing mucus out of the
breathing and coughing lungs.
exercises.
- Acute exacerbations of
- Anticipate the asthma can lead to respiratory
need for failure requiring mechanical
intubation and ventilation.
mechanical
ventilation.
- IV fluid therapy can be
- Administer IV beneficial for clients with
fluids and dehydration. Medications such
medication as as bronchodilators and inhaled
ordered. corticosteroids may be
prescribed.

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