ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE Ineffective airway After nursing

clearance related to interventions the
“Nahihirapan po decreased lung patient will be able
akong huminga” as expansion as to maintain airway
verbalized by the evidenced by patency, clear breath
patient dyspnea sounds

OBJECTIVES
- Body
weakness
- Absence of
cough;
ineffective
cough
- Wide eyed
look;
restlessness
- Difficulty in
verbalizing
- Alteration of
respiratory
rate