ASSESSMENT NURSING PLANNING IMPLEMENTATION RATIONALE EVALUATION

DIAGNOSIS
Subjective data: Ineffective airway Short term: 1.Assessed 1. Diminished breath After 8 hours of
“Nahihirapan po ako clearance related to After 8 hours of respiratory function sounds may reflect nursing care, the
huminga na parang purulent secretions nursing care, the noting breath sounds, atelectasis. Rhonchi, patient was able to:
may nakaharang sa as evidenced by patient will be able to: rate, rhythm, and wheezes and
ilong ko po” as inflamed nasal depth, and use of crackles indicate -Clear airways using
verbalized by the passages, abnormal -Maintain patent accessory muscles. accumulation of controlled coughing
patient. breath sounds, nasal airway secretions and techniques.
flaring, abnormal -Expectorate inability to clear -Expectorate sputum
Objective data: respiratoy rate, secretions without airways that may lead -Drink 3 to 4 L of fluid
-Labored and noisy rhythm and depth, assistance to use of accessory daily
breathing use of accessory -Adventitious breath muscles and -Understand the
-Nasal flaring muscles and dyspnea sounds will be increased work of necessity of adequate
-Crackles were absent. breathing. hydration, sputum
auscultated -Drink 3 to 4 L of fluid 2. Placed patient in 2. To aid breathing monitoring and taking
-Nasal passages are daily Fowler’s position and and chest expansion medications as
inflamed with purulent -Demonstrate support upper and to ventilate ordered.
discharge behaviors to improve extremities. basilar lung fields. -Perform postural
-Use of accessory and maintain airway drainage.
muscles clearance. 3. Helped patient 3. To help prevent
-Dyspnea -Participate in turn, cough and deep pooling of secretions GOAL MET.
-Vital signs: treatment regimen, breathe every 2 to 4 and to maintain
T: 36.8 ˚C within the level of hours. airway patency.
PR: 129 bpm ability and situation.
(tachycardia) -Identify potential 4. Encouraged fluid 4. High fluid intake
RR: 32 cpm complications and intake of 3 to 4 L daily helps thin secretions,
(tachypnea) initiate appropriate unless making them easier
BP: 90/70 actions. contraindicated. to expectorate.

Long term: 5. Suctioned as 5.To stimulate cough

-To facilitate the needed. and airways.
maintenance of a
supply oxygen to all 6. Provided adequate 6. To loosen
body cells. humidification. secretions.
-To recognize the
physiologic 7. Provided tissues 7.To prevent
responses of the and paper bags for spreading infection.
body to disease hygienic sputum
conditions disposal.
8. Monitored patient’s 8.To assess fluid
daily weight. balance.
9. Performed postural 9.To enhance
drainage, percussion, mobilization of
and vibration every 4 secretions that
hours or as ordered. interfere with
oxygenation.

10.Monitored and 10.To gauge

documented sputum theraphy’s
characteristics every effectiveness and
shift. detect possible
respiratory infection.

11.Taught patient 11. These steps

about: involve patient in own
-maintaining health care.
adequate hydration
-daily monitoring of
sputum and reporting
changes
-taking prescribed
drugs and avoiding
over-the-counter
respiratory drugs
-controlled coughing
and postural drainage
-the need to remain
active