ASSESSMENT DIAGNOSIS PLANING INTERVENTION RATIONALE EVALUATION

Subjective: After 2-3 hours of Independent:  To take advantage of After 2-3 hours of
 -“ Nurse, nahihirapan Ineffective Airway nursing  Elevate head of gravity decreasing nursing intervention the
akong huminga dahil sa Clearance related to intervention the  the bed/ change position pressure on the diaphragm patient:
plema ko” presence of patient would be every 2 hours and prn. and enhancing drainage
secretions. able to: of/ventilation of different Maintained airway
Objective: lung segment patency
Maintain airway  Monitor v/s signs especially
 -Productive
respiratory rate, note for  To evaluate degree of
patency Demonstrated reduction
cough respiratory distress compromise
of congestion with
- Dyspne Demonstrate breath sounds clear,
 Monitor respirations and
reduction of breath sounds, noting rate  Indicatives of respiratory respirations noiseless,
a congestion with improve oxygen
and sounds distress and/or
 -Wheezing breath sounds accumulation of secretions exchange.
clear, respirations  Evaluates client’s cough or
 -Coarse noiseless, improve gag reflex and swallowing  To determine ability to Displayed absence of
Crackles oxygen exchange. ability protect own airway tachypnea, dyspnea and
tachycardia
 -Irritable Display absence  Suction naso/tracheal/oral
of tachypnea, prn  To clear airway when GOAL MET.
 -Facial grimace excessive or viscous
dyspnea and
tachycardia secretions are blocking
 Lack of energy airway or client is unable
 Standby Oxygen at bedside
 Decreased to swallow or cough
performance  Insert oral airway as needed effectively
 Inability to
maintain usual  For emergency
routines
 Lethargic  Advice CPT to mother
 Vital Signs:  To maintain anatomic
position of tongue and
-BP: 110/70
 Increase fluid intake to at natural airway, especially
mmHg when tongue/ laryngeal
least 2000ml/day within
-PR: 112 bpm edema or thick secretions
cardiac tolerance
-RR: 30 cpm may block airway
-TEMP.: 39℃
 Helps on secretion of
excessive mucus
  Hydration can help
liquefy viscous secretions
Dependent: and improve secretion
Give clearance
expectorants/bronchodolators as
ordered
Aids in
reduction of
bronchospas
m and
mobilization of
secretions.