ASSESSMENT DIAGNOSIS OUTCOME PLANNING INTERVENTION EVALUATION

IDENTIFICATION

SUBJECTIVE: Ineffective Patient will Short term: Independent: After 8 hours of

airway clearance maintain clear, open nursing
related to airways as interventions, the
"Nahihirapan After 8 hours of Position the
increased evidenced by normal patient was able
akong huminga at nursing patient upright if
production of breath sounds, to:
ilabas ang plema interventions, the tolerated
mucus and normal rate and
kahit grabe na patient will:
retained thick, depth of Demonstrate
ang pag-ubo ko (I Rationale: to limit
viscous secretions respirations, and improved
am having Demonstrate abdominal contents
as evidenced by ability to ventilation and
difficulty Improved from pushing
abnormal effectively cough up adequate oxygen
breathing and ventilation and upward and
depth/rate of secretions after 1
expelling phlegm adequate oxygen inhibiting lung
respirations, week of nursing Verbalize
even if my expansion
abnormal breath intervention. decreased signs of
coughing is already Verbalize
sounds, and respiratory
severe) as decreased signs Regularly check the
ineffective or distress
verbalized by the of respiratory patient’s upright
nonproductive
patient” distress position to prevent
coughing. Establish a
sliding down in bed
breathing pattern
OBJECTIVE: Establish a
from 27
breathing Rationale: to
breaths/min to 20
pattern from promote better
Presence of breaths/min
27bpm to 20bpm. lung expansion and
rhonchi
GOALS MET
Presence of Long Term: improved air
wheezing sounds exchange Long Term:
Educate the
After 1-3 days of
Ineffective or patient about After 1-3 days of
nursing
absent cough optimal positioning nursing
interventions, the
(sitting position) intervention, the
patient will:
Abnormal and use of pillow or patient was able
respiratory rate, hand splints when to:
Demonstrate
rhythm, and depth coughing
improved ability
Demonstrate
to expectorate
Inability to Rationale: to improved ability to
retained
remove airway promote effective expectorate
secretions.
secretions coughing by retained
increasing secretions
Maintain
abdominal pressure
effective
V/S taken as and upward Maintain effective
breathing
follows diaphragmatic breathing pattern
pattern.
movement
T: 37.2 GOALS MET
PR: 79 Teach the patient
RR: 27 the proper ways of
BP: 110/80 coughing and
breathing

Rationale: to help
the patient in
doing this activity
as it is the most
convenient way to
remove most
secretions.

Encourage patient
to increase fluid
intake to 3 liters
per day unless
contraindicated
(e.g., heart
failure).

Rationale: to help
minimize mucosal
drying and
maximize ciliary
action to move
secretions

Dependent:
Give medications
as prescribed:
1. Antibiotics
2. Antitussives
3. Mucolytics
4. Bronchodilators
5. Expectorants
Rationale:

1. to eliminate the
bacterial
infection causing
the disease
2. to promote
patient comfort
by suppressing
and relieving
coughs
3. to increase
expectoration of
sputum by
reducing its
viscosity
4. to alleviate
bronchial
obstruction and
airflow
limitation by
relaxing the
muscles in the
lungs and
 widening the
airways
(bronchi)
5. to help cough up
mucus by
thinning and
loosening mucus
in the airways

Maintain humidified
oxygen as
prescribed

Rationale: to
reduce thickness of
secretions and aid
their removal

Perform
nasotracheal
suctioning as
necessary,
especially if cough
is ineffective

Rationale: to expel
secretions when
patients are unable
to do it
themselves

Collaborative:

Coordinate with a
respiratory
therapist for chest
physiotherapy as
indicated

Rationale: to
mobilize secretions
from smaller
airways that
cannot be
eliminated by
means of coughing
or suctioning

Provide postural
drainage,
percussion, and
vibration as
ordered
Rationale: to help
mobilize bronchial
secretions

Monitor serial
chest x-rays,
ABGs, and pulse
oximetry readings

Rationale: to
identify imbalances
in PaCO2 and
PaO2 which
indicates
respiratory fatigue

Refer to the
pulmonary clinical
nurse specialist as
indicated

Rationale: to
ensure that proper
treatments are
met
Perform intubation
as ordered if
secretions cannot
be cleared

Rationale: to help
prevent further
complications by
facilitating removal
of tenacious and
copious amounts of
secretions