Assessment Pathophysiology
Short Term Goal
Subjective
- “Hindi ko mailabas ung
ibang plegma,” as
inflammatory
verbalized.
Objective
- pale in appearance
increase production of
- dyspnea
-  uses accessory muscles
when breathing
airway constriction
- productive cough
- RR=41 cycles per minute
Nursing Diagnosis:
-Ineffective airway
clearance related to
secretions in the bronchi
Planning Intervention Rationale Evaluation
Irritant Dx
Short Term Goal - After 4 hours of
(inhalation) - Vital signs monitored > for baseline comparison nursing
-  After 4 hours of intervention, the
Nursing intervention, and recorded. goal is met through
airway patency will maintenance of
be - Assisted in semi- > proper positioning helps in airway patency and
response maintained, draining secretions reduction in
secretions will be Fowler’s position.
congestion.
readily expectorated
- Encouraged deep > This will promote proper
and there will be Long Term Goal
lung expansion
signs of reduction in breathing exercise
secretions - After 2 days of nursing
congestion.
intervention, the goal is
Tx
Long Term Goal met through decreased in
- Bedside care done > For Proper hygiene
respiratory rate of 14
- After two days the cylces per minute.
- Established rapport > For patient nurse
clients respiratory interaction
rate will be 12 – 20
dyspnea cycles per minute. - Administered prescribed >Prescribed meds such as
medications bronchodilators helps in
aiding effective airway
clearance
- Provided supplemental > Nebulization helps in
humidification via use of liquefy secretions for faster
nebulizer expectorating of secretions
Ex
- Encouraged client to > to liquefy the secretions for
increased fluid intake better patency
- Encouraged client to > to reduce congestion
expectorate secretions