NAME:

CUES NURSING OBJECTIVES NURSING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Subjective: Ineffective airway General Objectives: Independent:  To gain trust and
“Inuubo po, ang clearance related to > To facilitate the maintenance  Establish rapport with the patient cooperation. Goal met:
anak ko” as increased production of of the supply of oxygen to all  To provide baseline data. After 2 days of nursing
verbalized by the secretions secondary to body cells.  Monitor oxygen continuously.  Altered breathing pattern is intervention, the patient
patient’s mother. inflammation of the an indicative sign of was able to:
alveoli as evidenced by Specific subjective:  Assess the patient’s respiratory rate respiratory compromise and  Absence of
cough crackles on lower depth, rhythm, and effort. compensatory response to difficulty of
lobes and dyspnea. After 2 days of nursing  Encourage deep breathing and airway obstruction. breathing.
intervention, the patient will be coughing.  These techniques help  Relax respiration
able to.  Elevate the head of the bed and assess ventilations and mobilize  Clear breath
the patient for a semi-fowler position. secretions. sound
 Absence of difficulty of  Keep the environment allergen-free.  To provide maximal chest
Objective: breathing. expansion.
 Auscultate breath sounds.
Cough  Relax respiration
dyspnea  Clear breath sound
(+)Crackles lower
lobe
DEPENDENT:
Decrease breathe  To prevent allergic reactions.
sounds
 Administer Salbutamol nebule 1
nebule q 6 hrs  To ascertain status and note
 Maintain oxygen inhalation at 2 lpm progress.
Vital signs taken as
via nasal cannula as indicated.  To facilitate respiration by
follows
Collaborative: dilating the airways.
Temp: 38.2℃
PR: 125  Refer to RHU  To aid in respiration.
SPO2: 92%  Refer to the respiratory therapist for  For follow-up checkup.
RR 44bpm chest physiotherapy To mobilize secretions from small
airways that cannot be eliminated
by means of coughing and suction.