ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

S: “Nahihirapan Ineffective After 2 - Elevated the - For After 2 hours of

po siyang airway hours of head of the maximum nursing
huminga” as clearance proper bed or of better intervention
verbalized by related to nursing positioned lung patient able to
the S.O excessed or intervention patient in expansion expectorated
retained patient will sitting phlegm or
O: secretion expectorate position secretions.
-With secretion
productive - Demostrated -Promote
cough whitish and oxygenation
sputum encouraged before controlled
-With oxygen deep- coughing and
therapy via breathing most convenient
nasal cannula 2- and coughing way to remove
3 L/min exercises secretions
-With blackish (take two
discoloration of breath, hold
3rd and 4th for seconds
fingers and cough
- Weak in two or three
appearance times)
- Limited
movement - Encouraged
rest period -to prevent
fatigue
- Facilitated
back-tapping -to loosen
secretion
- Instructed
S.O and -to avoid cross-
patient to contamination
disposed the
used tissue
in proper
waste and
performed
hand
washing all
the time

Collaborative:
- Maintained
oxygen -to maintain clear
therapy as open airway
prescribed
 - Administered -to promote
medications pharmacological
as prescribed regimen

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

S: “nahihirapan
ako matulog
ang ingay tsaka
ang liwanag”
O:
-yawning

-With blackish
discoloration of
3rd and 4th
fingers
- Weak in
appearance
- Limited
movement

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION