Rhea Mae V.

Valles
BSN-III
Pt. R.B. 1y/o

Assessment Diagnosis Planning Intervention Evaluation

Subjective: Ineffective Within the shift and Nsg. Action Rationale Within the shift and
Inuubo saka may airway nursing intervention 1. Elevate the 1. To facilitate nursing intervention
plema sya as clearance the patient will be head part of breathing. the patient can be
verbalized by related to able to: the bed and 2. To mobilize able to:
patients mother. retained Expectorate align head secretions. Expectorate
secretions secretions in the 3. To know secretions
Objectives: readily. middle. and readily.
c difficulty Demonstrate 2. Assist the determine Demonstrate
of behavior to patient to the behavior to
expectoratin improve change patients improve clear
g phlegm clear airway. position need. airway.
c mild cough Maintain every 30 4. To establish Maintain
V/S taken as airway minutes. baseline airway
follow: patency. 3. Assess the data. patency.
patients 5. To liquefy
T: 37 condition. secretions.
P: 97 4. Monitor 6. To moisten
R: 24 and record secretions.
V/S. 7. To take
5. Encourage advantage
to increase of gravity
fluid decrease
intake. pressure on
6. Encourage the
steam diaphragm.
inhalation. 8. To limit
7. Encourage fatigue.
deep 9. To reduce
breathing bronchospa
exercise sm.
and 10. To
coughing determine
exercise. ability to
8. Encourage protect own
adequate airway.
rest period.
9. Administer
meds as
ordered.
10. Evaluate
patients
cough.