ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Ineffective airway GOAL: Establish rapport To gain pt’s trust. After 2 hours of
clearance related to nursing
increased production of intervention, the
Nahihirapan akong secretions. After 2 hours of nursing Suction airway, as To clear secretions. client manifested
huminga” as verbalized intervention the patient needed. lessened difficulty
by the patient will able to: of breathing as
manifested in RR
● Maintain normal from 26 cpm to 20
VS Monitor pulse
To verify maintenance cpm with the
oximeter.
and improvement in absence of nasal
● the patient will
oxygen saturation flaring and the
be able to
presence of calm
Objective: decrease
breathing
breathes per
Nasal Flaring minute from 27 Demonstrate the To decrease air training
to 12-20 pursed-lip breathing and for efficient
Productive cough and diaphragmatic GOAL MET
breathing
breathing

Vital Signs as follows:

Encourage patient to
increase fluid intake to prevent fatigue
BP: 100/80

Temp: 37.1
Encourage
PR: 90 opportunities of rest
To prevent the
and limit physical
RR: 27 situations that will
activities
aggravate the condition